Friday, May 29, 2015

Why does sore throat diagnosis and management cause controversy?

In 2007, Malcolm Gladwell spoke to the Society of Medical Decision Making in Pittsburgh. In his talk concerning decision making, he used sore throats as an example of “easy decision making.” Of course I stood up after his talk to point out that even sore throats raise complex decisions.

Just this year, my friend and colleague Jeffrey Linder titled his editorial about our recent pharyngitis paper: ”Sore Throat: Avoid Overcomplicating the Uncomplicated.” Sore throats often are uncomplicated. They often represent “just a sore throat”. But sometimes they portend more serious illness.

Many diagnostic delays occur because we physicians blow off the patient's complaints as simple or uncomplicated. But sometimes serious consequences follow these routines complaints. Talk to any college health physician and they will tell you that they worry about sore throats; they worry about missing something more serious.

What could they miss? Obviously, I am obsessed with the Lemierre Syndrome, which is relatively rare (I estimated in 2009 one in 70,000 adolescents or young adults each year) but often devastating. They could miss a peritonsillar abscess (or at least delay diagnosing it). Sore throats can precede acute rheumatic fever (not very often in the U.S. or Europe these days). Or sore throats can represent the initial presentation of HIV infection.

I could provide an even longer differential diagnosis for sore throats and often do that, boring the heck out of my colleagues and learners.

But back to the question I raised. I am sore throat obsessed. I see every sore throat as a potential diagnostic challenge. I write about sore throats and understand the red flags. Prior to assuming that the patient has an uncomplicated sore throat, I check off expected signs and symptoms and exclude the warning signs of something different. But then I am obsessed.

If we teach that sore throats are self-limiting and uncomplicated we will be correct over 90% of the time. But we have a responsibility to worry about the less common problems that present as “just a sore throat.” We need to know when to worry. Jeff should have titled his comments: “Sore throats—usually uncomplicated”.

We must teach more about when to worry. To label sore throats as uncomplicated without also presenting the fine print is potentially harmful, and can lead to diagnostic laziness.

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.
Thursday, May 28, 2015

Twisters, teapots and the land of (Doctor) Oz

Mehmet Oz and I have long been friends. This is because I actually know the man, not because I am an ardent fan of daytime television.

Rather the contrary, to be honest. I think television in general, daytime television in particular, and perhaps health-related programming above all, inevitably caters to the quick-fix, silver bullet, active ingredient mentality that prevails in our society. What actually ails us is generally much bigger than a sound bite or segment, as are what's needed to fix it, and how best to get there from here.

I understand the demands of television, however, knowing firsthand the prodding of producers to generate maximal tease and titillation, even when the professed intent is education. The balance struck involves compromise and results not in pure education, but in edutainment. The tone is showy, the language provocative. It's television.

When I have appeared on the Dr. Oz Show, as I have a number of times, I have inevitably been bombarded with emails afterwards from those inclined to think that whatever I talked about was “the thing“ they needed to turn their health around and wanting confirmation. Some such exchanges involved specific medical issues, and those are all confidential. In all other instances, however, my standard response has been: Stop watching daytime television! Get up and go for a walk instead.

It has been a tempestuous week in the land of Dr. Oz. And because we are friends, it has been a rather tempestuous week in my world, too, involving the customary vituperations of social media that ensue these days when people don't like something you've said. On close inspection, though, the source of these travails proves to be a far more twisting plot than first meets the eye, and something of a tempest in a teapot.

I suppose the story begins with green coffee bean extract.

The FTC sued a manufacturer of this weight loss supplement after the company in question generated some hyperbolic marketing claims following a segment on the Dr. Oz Show. The company has since settled with the FTC.

Dr. Oz was never a party to the litigation. He opined, of course, about green coffee bean extract on air, but did so as an uninvolved commentator. He has no financial stake in this product, nor any other discussed on the show, and could not, even if he wanted to, which he does not. There are rather strict stipulations in place about any such potential conflict.

But, Mehmet did put his toes over the line by using words like “magic” and “miracle” when talking about this, and perhaps other, products. Of course, he did not say it was magical or miraculous; rather, he said that “some have called it ...” But that is still a claim by proxy, and untoward. When I have expressed my view to Mehmet that “magic” and “miracles” have no place in the medical lexicon, his only response has ever been: Agreed, mea culpa.

That was his response, too, when Sen. Claire McCaskill delivered a public rebuke for his alleged peddling of what was referred to routinely in the media as a “weight loss scam.”

Superficially, this might be wholesome, consumer protection, and appropriately spearheaded by Sen. McCaskill, who chairs the subcommittee on consumer protection. But there are a couple of considerations that suggest it may be something else.

For one thing, green coffee bean extract for weight loss is not a scam. It's certainly not magical or miraculous, nor a panacea, but the weight of evidence suggests it works.* The citations below include studies showing both promising effects in people and mechanisms of action in animal research. I am by no means suggesting that this bibliography establishes the utility of the product, but at a minimum, it indicates the product is the subject of genuine scientific inquiry. It also indicates that a fair amount of reading is required before presuming to opine.

While green coffee bean extract is certainly not the answer to epidemic obesity, it's clearly not a “scam” either. In fact, it is almost certainly safer, and apparently nearly as effective, as the dugs approved for weight loss by the FDA, all of which are quite lousy. I have no financial stake in either, and would certainly recommend a patient of mine try GCBE before any of the drugs now on the market.

Then, there is the concern raised in several media outlets that Sen. McCaskill's ire directed at Dr. Oz may have had less to do with GCBE, weight loss, or the customary penchant for titillation and hyperbole on TV, and more than meets the eye to do with his advocacy for GMO labeling. According to Sourcewatch.org, Sen. McCaskill is among the prominent recipients of campaign finance support from Monsanto. That may not be directly relevant to this plot, but wherever you examine the Oz story, from root to leaf, the name that comes up even more often than Mehmet's is: Monsanto.

This isn't really the time to go too far into the weedy issue of genetic modification of crops. I will say that from my perspective, the notion that GMOs are always good and safe is shockingly dismissive of the law of unintended consequences, and the innumerable unintended follies of history. I will also say that the notion that GMOs are inevitably bad is at least comparably fatuous. It's a method, and the results can be good or unintentionally bad. The arguments in question, however, have nothing to do with use of the method, and pertain only to disclosure. Even on the issue of labeling, there are arguments going both ways. But I think we must concede that withholding information from consumers on the basis that they won't know what to do with it is a rather significant foray into Nanny-state ideology. Rather shocking to find Monsanto in the position of “nanny,” with an entourage of the very republican support that generally assaults any such proposition, but it is what it is.

The timing of all this does not appear to be happenstance. A bill is currently being advanced in Congress that would prohibit any states from requiring GMO labels. Given the usual devotion of republicans to state autonomy, let alone opposition to nanny-ing, republican sponsorship of this bill borders on the surreal. But apparently, what Monsanto wants, Monsanto gets. And all this fuss, by the way, not over some radical, uniquely American fastidiousness, but over labeling and disclosure that most developed countries around the world already require.

As it turns out, we can't avoid the weeds entirely, because going into the weeds is directly relevant to Monsanto's fingerprints all over this tale. The real concern about Monsanto among those well informed on the topic is not the GMO crops, per say, but the glyphosate-containing herbicide, Roundup, sprayed on them. Crops have been genetically modified specifically to tolerate high exposure to Roundup, so that high doses may be used to kill all of the competing “weeds.”

I leave for you to chew as the cud moves you on the financial advantages of selling both the seed crops designed to tolerate a potent herbicide, and the potent herbicide the crops are designed to tolerate. I have to presume whoever cooked up that business model got one helluva Christmas bonus.

Speaking of Christmas, it was in the Christmas issue of 2014 that the British Medical Journal added wind to this incipient cyclone by publishing a paper challenging the substantiation of claims made on medical TV shows, the Dr. Oz Show notable among them. This engendered allegations of charlatanism among those apparently eager to see their mightily celebrated colleague fallen, but the “truth” was quite another story.

Writing on the BMJ website, the authors acknowledged that the recommendations on TV were substantiated by randomized trials almost exactly as often as prevailing recommendations in clinical practice; and slightly more often than guidance in position statements. They also disclosed that the kind of “recommendation” they found to be unsubstantiated with RCTs included: cover your nose and mouth when you sneeze; don't buy products out of vending machines oozing goo; and confer with your own doctor before acting on the advice of a doctor you saw on TV.

Seriously.

So, yes, it's true, there are apparently no RCTs to show better outcomes when people confer with their own doctors before acting on medical advice. There are, to my knowledge, no RCTs to indicate it's better to treat bullet holes through the chest with emergency surgery rather than watching them bleed, either, but I'm OK with it, in both cases. As noted, tempest in a teapot.

Now, back to the bigger issue: Is Roundup safe? I don't know. Argentina doesn't seem to think so.

Studies have suggested that glyphosate, alone, is acceptably safe at the levels routinely encountered. But Roundup is not just glyphosate, and independent scientists reporting in the peer-reviewed literature have raised concerns that the whole herbicide may be toxic in ways greater than the component parts. Subsequent reports of potential Roundup toxicities have been published by the same group again, and again, and again. I would gladly defer to an unaffiliated toxicologist to say how concerning this literature is, but my own training certainly allows me to say that reports of “no cause for concern” are premature, and unjustified. The shadow of legitimate doubt has been cast.

What, then, of Monsanto in the Oz-related turbulence of late? I have absolutely no idea if Monsanto-related provocations had anything to do with Sen. McCaskill's rebuke. But I must say that a highly publicized reprimand from a sitting U.S. Senator for a television segment about a weight loss supplement that is probably both safe and somewhat effective seems a remarkable instance of aiming an RPG at a gnat.

Monsanto's involvement in the latest twist of the story, however, seems all but certain, according to sources that include Al Jazeera America, and for those who prefer only truly erudite journalism, People Magazine. The initial headlines, and echoes in cyberspace, all contended that “prominent physicians” were requesting the ouster of Dr. Oz from the Columbia University faculty. The reality is that a group of 5 physicians with ties to Monsanto apparently invited along 5 friends to make, a minion? And then masquerade as the voice of the impartially prestigious, and righteous.

That such echoes in cyberspace were propagated by, among others, those professing to defend science and evidence, who apparently didn't bother to check the evidence underlying the claims in, or about, the already infamous letter, can be a story for another day. Suffice to say now that claims of defending the public from the hypothetical harms of medicine-on-television by use of evidence should, really, provide some evidence of ever having defended the public from any actual harm. Otherwise, evidence is espoused, but propaganda is dispensed. It may be some such groups are simply the extended phenotype of an Internet troll, not really concerned with defending anyone from anything -- and simply committed to trolling for their own notoriety. As noted, that can be a story for another column, and another day.

None of this is to suggest that medical advice on television has been entirely vindicated. As noted, I have long had my own concerns about it. The legitimate practice of medicine is full of uncertainties and delays; doubts, and disappointments.

Television, in contrast, needs to be much about drama, and titillation, and perennially perky. When I worked on-air for Good Morning America (which, by the way, has also addressed the letter-of-righteous-indignation story, reaffirming not only the conflicted interests of the letter writers, but also the felony and prison term of one of their august number), I found the reconciliation of the 2 a challenge. I suspect Mehmet does as well at times. The rest of us have cause to recognize the tensions that govern any attempt at “education” on television. We also have cause to wonder what is wrong with the modern practice of medicine, when so many find the understanding, empathy, and empowerment they hope to get from their own doctor, only from a doctor they see on TV.

So we come to the end of this rendition of a tale with more twists than the cyclone that lifted Dorothy's house off its foundation. We are, I think, invited to reach the same conclusion imparted to Dorothy when she landed. If what is supposed to be a story about the distortions born of TV medicine is actually much about the profit-driven machinations of a global agri-business, and the dubious self-promotions of the self-serving and flagrantly conflicted, then things may not be as they seem. We are someplace other than where we started, whether over the rainbow or otherwise. We are, as the saying goes, not in Kansas anymore.

*Selective bibliography for green coffee bean extract:

1) Marcason W. What Is Green Coffee Extract? Journal of the Academy of Nutrition and Dietetics. 2013;113(2):364.

2) Clifford MN. Chlorogenic acids and other cinnamates - nature, occurrence, dietary burden, absorption and metabolism. Journal of the Science of Food and Agriculture.2000;80(7):1033-1043.

3) Shimoda H, Seki E, Aitani M. Inhibitory effect of green coffee bean extract on fat accumulation and body weight gain in mice. BMC Complement Altern Med.2006;6:9.

4) Naczk M, Shahidi F. Phenolic compounds in plant foods: chemistry and health benefits. Nutraceuticals and Food. 2003;8(2):200-218.

5) Clifford MN. Chlorogenic acids and other cinnamates - nature, occurrence and dietary burden. Journal of the Science of Food and Agriculture. 1999;79(3):362-372.

6) Olthof MR, Hollman PC, Katan MB. Chlorogenic acid and caffeic acid are absorbed in humans. J Nutr. Jan 2001;131(1):66-71.

7) Henry-Vitrac C, Ibarra A, Roller M, Merillon JM, Vitrac X. Contribution of chlorogenic acids to the inhibition of human hepatic glucose-6-phosphatase activity in vitro by Svetol, a standardized decaffeinated green coffee extract. J Agric Food Chem. Apr 14 2010;58(7):4141-4144.

8) Ho L, Varghese M, Wang J, et al. Dietary supplementation with decaffeinated green coffee improves diet-induced insulin resistance and brain energy metabolism in mice. Nutr Neurosci. Jan 2012;15(1):37-45.

9) Hemmerle H, Burger HJ, Below P, et al. Chlorogenic acid and synthetic chlorogenic acid derivatives: novel inhibitors of hepatic glucose-6-phosphate translocase. J Med Chem. Jan 17 1997;40(2):137-145.

10) Laranjinha JA, Almeida LM, Madeira VM. Reactivity of dietary phenolic acids with peroxyl radicals: antioxidant activity upon low density lipoprotein peroxidation.Biochem Pharmacol. Aug 3 1994;48(3):487-494.

11) Nardini M, D’Aquino M, Tomassi G, Gentili V, Di Felice M, Scaccini C. Inhibition of human low-density lipoprotein oxidation by caffeic acid and other hydroxycinnamic acid derivatives. Free Radic Biol Med. Nov 1995;19(5):541-552.

12) Tanaka K, Nishizono S, Tamaru S, et al. Anti-Obesity and Hypotriglyceridemic Properties of Coffee Bean Extract in SD Rats. Food Sci Technol Res. 2009;15(2):147 - 152.

13) Cho AS, Jeon SM, Kim MJ, et al. Chlorogenic acid exhibits anti-obesity property and improves lipid metabolism in high-fat diet-induced-obese mice. Food Chem Toxicol. Mar 2010;48(3):937-943.

14) Thom E. The effect of chlorogenic acid enriched coffee on glucose absorption in healthy volunteers and its effect on body mass when used long-term in overweight and obese people. J Int Med Res. Nov-Dec 2007;35(6):900-908.

15) Welsch CA, Lachance PA, Wasserman BP. Dietary phenolic compounds: inhibition of Na+-dependent D-glucose uptake in rat intestinal brush border membrane vesicles. J Nutr. Nov 1989;119(11):1698-1704.

16) Suzuki A, Yamamoto N, Jokura H, et al. Chlorogenic acid attenuates hypertension and improves endothelial function in spontaneously hypertensive rats. J Hypertens. Jun 2006;24(6):1065-1073.

17) Bugianesi R, Salucci M, Leonardi C, et al. Effect of domestic cooking on human bioavailability of naringenin, chlorogenic acid, lycopene and beta-carotene in cherry tomatoes. Eur J Nutr. Dec 2004;43(6):360-366.

18) Plumb GW, Garcia-Conesa MT, Kroon PA, Rhodes M, Ridley S, Williamson G. Metabolism of chlorogenic acid by human plasma, liver, intestine and gut microflora.Journal of the Science of Food and Agriculture. 1999;79(3):390-392.

19) van Dijk AE, Olthof MR, Meeuse JC, Seebus E, Heine RJ, van Dam RM. Acute effects of decaffeinated coffee and the major coffee components chlorogenic acid and trigonelline on glucose tolerance. Diabetes Care. Jun 2009;32(6):1023-1025.

20) Ota N, Soga S, Murase T, Shimotoyodome A, Hase T. Consumption of Coffee Polyphenols Increases Fat Utilization in Humans. Journal of Health Science (Japan).2010;56(6):745-751.

21) Watanabe T, Arai Y, Mitsui Y, et al. The blood pressure-lowering effect and safety of chlorogenic acid from green coffee bean extract in essential hypertension. Clin Exp Hypertens. Jul 2006;28(5):439-449.

22) Monteiro M, Farah A, Perrone D, Trugo LC, Donangelo C. Chlorogenic acid compounds from coffee are differentially absorbed and metabolized in humans. J Nutr. Oct 2007;137(10):2196-2201.

23) Zhao Y, Wang J, Ballevre O, Luo H, Zhang W. Antihypertensive effects and mechanisms of chlorogenic acids. Hypertens Res. Apr 2012;35(4):370-374.

24) Dellalibera O, Lemaire B, Lafay S. Svetol green coffee extract induces weight loss and increases the lean to fat mass ratio in volunteers with overweight problem.Phytotherapie. 2006;4(4):194-197.

25) Ayton Global Research. The Effect of Chlorogenic Acid Enriched Coffee (Coffee Shape) on Weight When Used in Overweight People. 2009.

26) Vinson JA, Burnham BR, Nagendran MV. Randomized, double-blind, placebo-controlled, linear dose, crossover study to evaluate the efficacy and safety of a green coffee bean extract in overweight subjects. Diabetes Metab Syndr Obes. 2012;5:21-27.

27) Onakpoya I, Terry R, Ernst E. The use of green coffee extract as a weight loss supplement: a systematic review and meta-analysis of randomised clinical trials.Gastroenterol Res Pract. 2011;2011.

28) Heckman MA, Weil J, Gonzalez de Mejia E. Caffeine (1, 3, 7-trimethylxanthine) in foods: a comprehensive review on consumption, functionality, safety, and regulatory matters. J Food Sci. Apr 2010;75(3):R77-87.

29) Therapeutic Research Faculty. Green Coffee. Natural Medicines Comprehensive Database. 2013.

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.
Wednesday, May 27, 2015

Screening, decolonization and environmental decontamination for MRSA in nursing homes doesn't work

Just in the past couple of weeks, we've written about pneumonia prevention bundles, multidrug-resistant organisms prevention bundles, and spread of Staphylococcus aureus all in nursing homes. It's like no one cares about acute care facilities anymore! (humor) There is now more great data for those charged with managing infection control in nursing homes.

Cristina Bellini and colleagues from Lausanne University Hospital in Switzerland published the results of cluster-randomized trial of a methicillin-resistant S. aureus (MRSA) prevention bundle in 104 nursing homes (53 intervention, 51 control) in the April issue of Infection Control & Hospital Epidemiology. All residents in intervention and control nursing homes, who gave consent, were screened for MRSA carriage at study entry and 12 months thereafter on a single day in each nursing homes. Newly admitted or readmitted residents were screened when admitted to the nursing homes. Screening included nasal, groin and ulcer swabs along with urine cultures if residents had an indwelling catheter. In the intervention nursing homes MRSA colonized residents underwent decolonization along with environmental decontamination.

The primary decolonization bundle included 5 days of nasal mupirocin, 5 days of chlorhexidine gluconate (CHG) oral rinse twice per day, 5 days of CHG showers including CHG shampoo on day 1 and 5. Environmental disinfection included daily clothing changes for 5 days, new linens on day 1 and day 5, and daily bed/table/phone/remote/wheelchair/walker disinfection with 70% alcohol. A lot of steps.

Unfortunately, the MRSA decolonization and decontamination bundle was not successful. The baseline prevalence of MRSA was 8.9% in both groups. The rate declined in intervention units to 5.8% in the intervention unit and 6.6% on the control units after 12 months (P=0.66) No matter how researchers analyzed the intervention, the MRSA bundle intervention did not reduce MRSA prevalence compared to controls. This was despite the fact that the participation rate was 87%.

A limitation of this study was that they only measured prevalence and not individual level acquisition of MRSA. It is possible that by measuring prevalence they missed detecting benefits of the intervention related to reduced patient-to-patient transmission of MRSA. In any case, as I said last week about the study in Clinical Infectious Diseases, congratulations to the authors and journal (this time ICHE) for publishing this important negative study.

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.
Tuesday, May 26, 2015

Preventive medicine: on being a bad patient

(Readers beware: this is the rant of a curmudgeon. Take with at least 1 grain of salt)

I am, or will be, a “bad patient.” The “good patient” accepts advice gracefully. The “bad patient” may not be a bad person, but does not play the part of the patient well. The word patient comes from the Latin word root pati, to suffer. The “good patient” suffers well, and accepts help from a physician, who Merriam Webster defines as someone skilled in the art of healing. This relationship is one in which the roles are well defined. When the patient is not actually suffering and is even more confusingly “skilled in the art of healing” the roles get really wonky. I will be this kind of “bad patient.”

One way in which I do not play the part of the patient well regards preventive medicine. I am getting to an age at which various things are recommended in order to reduce my risk of developing some dread disease. When it comes to these recommendations, I find that I have become quite the picky consumer. I would dearly love not to get a preventable disease, but after more than 2 decades of practicing primary care medicine, I have seen too many undesirable consequences of perfectly benign sounding medical tests.

Breast cancer screening:

I don't avail myself of mammograms. I did once, and that was fine. Starting age 50 I was supposed to get mammogams every other year, according to the U.S. Preventive Services Task Force (USPSTF). Maybe I'll get another one sometime if the data gets better. A Canadian study showed no significant effect of regular mammography on breast cancer mortality in average risk patients, though women who get regular screening do get more treatment for breast cancers, including mastectomies and radiation therapy.

Colon cancer screening:

I haven't had a colonoscopy. In this test, a fiberoptic scope would be introduced into my lower intestine by way of the rectum and the whole colon would be visualized with the expectation of finding and removing polyps before they become cancers, or seeing cancers before they become incurable. USPSTF said I should have started those at age 50, but the data for women without suggestive family histories of colon cancer is not convincing and the potential for something to go wrong definitely exists. An inadequately sterilized colonoscope could introduce some unfriendly bacterium into my gut. I think I like my flora as it is, thank you. The procedure to clean out my gut, drinking a half gallon of plyethylene glycol solution until my bowels run clear, which is required before the procedure, may be fine, but I'm not entirely sure that a day of rapid intestinal transit is good for me. Intravenous sedation, which is usually given in order to make this procedure tolerable, has a small risk of killing me and will make me goofy, though possible in a pleasant way. I will watch for updates, but I'm thinking I may have this procedure when I'm 60. Maybe. I prefer to reduce my risk of colon cancer by maintaining a healthy weight and eating a diet rich in fruits and vegetables.

Cervical cancer screening:

Pap smears. The recommendations have changed and the schedule is less onerous, but since I had regular yearly pap smears until several years after becoming monogamous, my chance of having a new human papillomavirus infection is vanishingly unlikely, and it is that infection that leads to cervical cancer, which is the only cancer that a pap smear reliably detects. I think I may be done with pap smears.

Hypertension:

Blood pressure screening is another story. Detection of hypertension and treatment of high blood pressure saves lives, prevents strokes, heart attacks and kidney failure. I can do it myself, and if my blood pressure is persistently high, I will actually see a doctor and start medications. Let that not happen, because I will not submit gracefully to someone else's opinion on which medication I should take. Unless, of course, they are right. Often I see patients started on some medication which just came out and is available in the doctors free sample cabinet. That one I don't want. It will be expensive to refill and we will know very little about how well it works in the long run. Don't I sound annoying?

Osteoporosis:

Bone density testing. There are machines that will shoot photons at my bones and tell me if I am developing osteoporosis. I should get this done at age 65. Mostly I should avoid breaking bones, though, since that is the real problem. It matters not a bit if my bones are as fragile as dry corn stalks so long as they never break. Staying strong and agile is the best way to avoid falls and fractures. If I find out that my bones are thinning, the main option for bone strengthening are the bisphosphonates, such as alendronate (Fosamax). These are medications which, if they don't get caught in the esophagus and cause a terrible ulcer, which they are known to do, and they don't get entirely eliminated, unabsorbed, due to having taken food with them to avoid getting the esophageal ulcer, will enter my bones to reduce the natural breakdown of bone by my osteoclasts, thus messing up the delicate balance of osteoblasts and osteoclasts that creates normal bone architecture. This will reduce my risk of breaking a hip or vertebra if I fall, but will put me at risk for a rare but horrific breakdown of bone in the jaw called osteonecrosis. So I will work hard on my strength and balance, eat a good diet and encourage the effects of gravity on my bones via weight bearing exercise. Luckily I am not yet 65, so I can decide on this test later. I'm leaning toward not.

But what about taking estrogen for my bones? It is primarily the loss of natural estrogen at menopause that will lead to osteoporosis. Will I take estrogen, then, since I am in menopause? The drawbacks are a slight increase in breast cancer, but without a convincing increase in breast cancer deaths, so this is a wash as far as I'm concerned. There is a slight increased risk of developing blood clots to the legs and lungs, but I didn't get those when I made estrogen with my natural ovaries so I doubt I'll get them with a small dose of exogenous estrogen. There is a slight risk of developing endometrial cancer when taking estrogen if progesterone is not taken as well to maintain a thin endometrium. Birth control pills, which are about 6 times the estrogen dose of a standard estrogen replacement pill, have a progesterone agent in them, and that may well be adequate to maintain a thin and healthy endometrium. I can also check my endometrium regularly with a quick transabdominal bedside ultrasound and make sure everything is looking hunky dory. Will I get a stroke or heart attack with estrogen? The results from the Women's Health Initiative suggested that this might be a risk, but further study has suggested that it may have been the relatively high dose of medroxyprogesterone that caused that problem, and there was no actual survival disadvantage in long term estrogen users. Will estrogen help me avoid hot flashes and vaginal dryness? Yes, it will. Perhaps I shall take one sixth of a birth control pill daily, since that is cheap and generic and will avoid wallet toxicity.

What about vaccinations? Yes, with no hesitation. Yearly flu shots, though I recognize my potential benefit from these is low, pneumonia shots when the time comes, tetanus and acellular pertussis, yes, and appropriate travel vaccinations with the possible exception of yellow fever. (There is a longer discussion of that here.)

How about obsessing about my cholesterol? The present recommendations about cholesterol lowering are to treat patients with a 10 year risk of cardiovascular events of 7.5%. The calculator for this has recently been shown to overestimate this risk, but I have always been in the vanishingly unlikely range, which means that I need not know my numbers. I have checked them occasionally and they are not pristine, but it is not clear to me what intervention would be most likely to lower my already low risk of cardiovascular disease. Certainly there is no indication for medications. I might become primarily vegetarian and eat fish when I can get it, embracing the Mediterranean diet. There is no good data to tell me which fats I should eat, but it seems wise to be moderate and avoid trans-fats which don't naturally occur in the foods I love anyway.

How about exercise? Exercise seems to play an important part in preventing all kinds of things I don't want, from diabetes to dementia. It will control my weight, which will help me avoid hypertension and cancer. It will improve my balance so I will avoid falling and breaking bones. I will be more likely to be nimble enough to jump out of the way of an oncoming bus or bicycle. Yes to exercise. Long walks in the woods, cross country skiing, visits to the gym, bicycling, swimming, canoeing.

How about a regular physical exam? Not sure. So far it's been no for me, but yes for my patients. A physical exam is no longer really recommended, though there are many pieces of the physical exam that are part of what we recommend to patients as prevention. I think a physical exam is actually a good idea, but more as a prolonged discussion of these recommendations and to develop shared goals. Examining the body is not a bad idea, either. As we age, our bodies do weird things. A toe will point in the wrong direction, there will be a lump or a pain or a vague dysfunction, none of them severe enough to warrant a visit to the doctor, but each one deserving attention and maybe explanation. In total, these little irritations may paint a picture of a whole organism which needs some kind of intervention in order to be as healthy and vital as possible. If this kind of an evaluation and discussion is a physical, then yes, definitely, and I might even want one.

So am I actually a bad patient? Since I am not a patient, it is still a moot point. They say doctors make terrible patients. We will just have to see, when the time comes.

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.

Whistleblowers, then and now

My son and I recently saw the Oscar-winning documentary “Citizen Four” about NSA contractor and leaker Edward Snowden. It's a riveting film, because it not only covers the topic of unwarranted government surveillance, but it was made in real time, as Laura Poitras, the filmmaker, was in Hong Kong filming Snowden and reporter Glenn Greenwald as the first stories broke and Snowden's identity became known.

It's an interesting coincidence, then, to read the obituary of an almost-whistleblower by the name of Dr. Irwin Schatz. Schatz is remembered for writing a letter to the authors of a medical journal article in 1965 about the infamous “Tuskegee Syphilis Study,” in which black men in the South, primarily Alabama, were followed without treatment for decades to learn about the natural history of untreated syphilis. The study was administered by the United States Public Health Service, and is widely remembered and taught as an egregious example of bad medical ethics. If the profession's dictum is “First, do no harm,” the Tuskegee study caused irreparable harm by not treating an illness for which there was a surefire cure: penicillin.

The obituary contains all of Schatz’ 3-line letter, which was sent to the study's senior author:

“I am utterly astounded by the fact that physicians allow patients with potentially fatal disease to remain untreated when effective therapy is available. I assume you feel that the information which is extracted from observation of this untreated group is worth their sacrifice. If this is the case, then I suggest the United States Public Health Service and those physicians associated with it in this study need to re-evaluate their moral judgments in this regard.”

Unfortunately, when his letter went unanswered, he did not persist. It took the whistleblowing of a Public Health Service investigator named Peter Buxtun to finally bring the study to a close in 1972. Unsurprisingly, it took Buxtun a number of tries to bring the unethical nature of the study to light. He first tried to go through official channels, as early as 1966, but was met with resistance on several occasions. It wasn't until he leaked the information to a reporter at the Washington Star that the story received enough attention to stop the study.

Snowden registered his concerns with his superiors, too, before ultimately deciding to go to the media because no one in the hierarchy seemed poised to question the status quo.

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.
Monday, May 25, 2015

Which social media platform should doctors use first?



Which social media platform should doctors use first?

My recommendations are LinkedIn or Doximity.

These are professional social networking sites where a profile on one of these sites is no more than a digital translation of your resume. There are some differences between the 2. I think LinkedIn generally gets ranked higher on Google searches, but Doximity has staff members who can enter your CV into their system for you. It’s a great time saver.

Also, Doximity profiles get simulcasted on a U.S. News & World Report website, and that’s like getting 2 profiles for the price of 1.

So, my recommendations for your first social media platform: LinkedIn or Doximity.

Better yet, do both.

Kevin Pho, MD, ACP Member is co-author of Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. He is founder and editor of KevinMD.com, where this post originally appeared.

That 'old-school' physician that we should all be like

A couple of weeks ago I was on-call and had to go down to the emergency room to see a patient. Before I entered the room, I was told that the patient was accompanied by her long-time physician who was a bit “crazy and old school.” “Hmmm … that's strange … why would her physician be in the room with her?” I thought to myself.

When I went in to introduce myself, sure enough sat next to her was an elderly physician probably in his late 70s or early 80s. After he greeted me with a warm and friendly handshake, he told me that he had practiced medicine in the local area for the last several decades. I still continued to wonder exactly what he was doing there and this thought persisted for the next few minutes. However, as I got further into the interview, I quickly realized just why he was sitting by his patient's side. This doctor had cared for the patient for at least the last 30 years, was in the process of winding down his practice, but felt compelled to come and visit his patient (with no financial incentive to do so) as soon as he heard she was being admitted to the hospital.

The patient, elderly herself and hard of hearing, wasn't able to give me a complete history. But that was okay, because her doctor knew her inside out. Every little detail. When I asked about her medications, he pulled out a notepad and scrolled through it, where he had handwritten all her prescriptions. The relationship between them was obvious, and the respect the patient had for her doctor was also very palpable. After I had got through my interview and examination, explained my findings and treatment strategy (by this time the patient's sister had also arrived), it was approaching 10 p.m. The physician said that he felt more comfortable that his patient was in good hands and left as she was being transferred up to the medical floor.

My interaction with that elderly physician that evening really caused me to reflect on a couple of things. Firstly, the fact that the ER staff and even the physician colleague who had signed the patient over to me thought that the physician was a bit odd for sitting by his patient's side in the ER. How have we got to the stage where a genuine and caring doctor has become the odd one out? Then there's the reality that his generation represents precisely what a personal physician should be. A solid physician with great clinical skills and highly respected by both the patient and their family. Unlike what medicine has become today, this was a doctor who would look you in the eye and think carefully and thoroughly through the diagnosis and treatment plan. It was obvious when he spoke to me that his clinical reasoning skills were top-notch. He wasn't a doctor who was glued to his computer screen, having to spend the majority of his day clicking and typing away—about as far away as possible from the “type and click bot” doctor that is proliferating at today's medical frontlines. The majority of his time was spent in direct patient care and not bogged down by healthcare information technology. Without the aid of a computer, he was able to reel off highly detailed parts of her medical history and previous hospitalizations. He had obviously spent all of his career being his own boss and hadn't been constantly mired in the next administrative battle. This was a doctor who knew his trade and the practice of good medicine.

Sadly, I also realized how this doctor was a dying breed and how much we've lost in our rush to mechanization and consolidation. His solo practice is sure not to be taken over by another similar doctor. But there was also one other recurrent thought that stayed with me for the next few days. I kept thinking about the words that were spoken to me before I entered the room about the “crazy old-school physician.” These words echoed in my mind and I couldn't help conclude that it's actually we (the current generation of physicians) who are the only crazy ones. That old-school physician is exactly who we should all be aspiring to be like.

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.
Friday, May 22, 2015

Teaching diagnostic reasoning

Amidoc wrote this comment:

Thank you for sharing this with us.

How about focus on teaching how to avoid clinical errors during medical school and residency? I am sure someone smart can come up with a curriculum and the apply it in real life.

Yesterday I gave Grand Rounds at my alma mater, the Medical College of Virginia in Richmond (sometimes called VCU but I reject the relabeling). The title, “Learning to Think like a Clinician,” is pithy, but may not convey the essence of the talk. In this talk I present patients whose diagnostic process helps us understand the source of diagnostic errors as well as the path to diagnostic excellence. The talk borrows heavily from cognitive psychology and particularly 2 books, “Thinking Fast and Slow,” by Daniel Kahneman and “Sources of Power,” by Gary Klein.

This talk and those books outline a curriculum for understanding the basis of diagnostic reasoning. As noted a physician as Jerome Kassirer, MD, former editor of the New England Journal of Medicine, has called for diagnostic reasoning to be included as a basic science throughout medical school. He and Rich Kopelman started the NEJM Clinical Problem Solving exercises (another great way to learn medicine and the diagnostic process).

But I would argue that writing a curriculum is not the answer. The answer must come from improved clinician educators. We assume that anyone who finishes a residency and/or fellowship can teach medical students and residents. But skilled medical education requires specific skills. One skill that some cannot master is the skill of making explicit ones thought processes. Our research on ward attending rounds, and my anecdotal experience in talking with many students and residents, teaches us that learners want to understand how the process works. So we need to trainer the educators on how to teach medicine. We should develop more rigorous training for medical educators so that they can help their learners grow into great diagnosticians.

Unfortunately, we who value the art of diagnosis are handicapped because diagnostic excellence is difficult to document with measures. We cannot measure diagnostic error rates, because diagnoses are often difficult and gold standards are difficult to determine.

But we do have a responsibility to try. We should value diagnostic reasoning more as our learners know that they need to learn these skills.

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.
Thursday, May 21, 2015

Is the FDA unKIND?

Chances are, if you have ever ventured just about anywhere outside of your own house, that you are familiar with the increasingly ubiquitous KIND bars. And chances are as well, if that place you call home is anywhere other than under a large rock, you are now aware of KIND's kerfuffle with the FDA.

The FDA is wrong.

Let's be clear: I am a supporter of the FDA. A former commissioner of the agency, and subsequently our former dean of medicine at Yale, is a highly respected colleague and personal friend. I have friends working at the agency now. I have advocated for the agency in various ways on many occasions, visited with scientists there for various reasons, and signed petitions in defense of the funding the agency needs and deserves to do its demanding and important work. But that doesn't change the conclusion here: The FDA is wrong.

I hasten to note that I am also a supporter of KIND. The CEO of KIND, Daniel Lubetzky, is also a personal friend, and quite literally one of the best people I know. Leaving aside the usual stuff, loving husband, devoted father, and the like, Daniel has been recognized repeatedly, and appropriately, as a paragon of corporate responsibility. He has made doing the “KIND” thing intrinsic to his company's DNA. He runs a global non-profit devoted to, of all things, world peace. I love this guy, and I love the company that embraces his exemplary commitment to honesty, integrity, and genuine virtue.

I append, as well, that KIND has sponsored 2 studies in my lab, both resulting in peer reviewed publication (the second paper is now in press). But let's be clear: I did not decide I liked KIND because the company funded research in my lab. Rather, they funded research in my lab after I decided I liked them, felt their product deserved to be studied for its health effects, and approached them about sponsorship.

In general, all the wrong concerns tend to be raised about research sponsorship. Anyone who thinks a vested interest should never fund research is something of a hypocrite if they have ever been to a pharmacy; virtually every drug at our disposal got there via pharmaceutical industry research funding.

What matters to the reliability of research findings is the methods that guard against bias, not the existence of bias in funder, or researcher. I have been biased, meaning I was hoping for a particular outcome, with every study I have ever run, whether the bills were paid by a foundation, a company, the NIH, or the CDC. Why run a study when you don't care how it turns out? I always care, and that, by definition, is bias. We thus build in methods to make sure such inevitable researcher bias does not result in biased research measures.

As for the outcome of those KIND bar studies: Both were positive, demonstrating benefits related to cardiometabolic health, appetite, weight and body composition. The science we have lines up quite well with both common sense, and the company's intentions: These are healthy snacks.

Which brings us back to the conflict with the FDA. In brief, KIND received a letter of reproach from the FDA for use of the word “healthy,” on the back and in small print, on 4 of their snack bar wrappers which in a very specific way fail to qualify, under the FDA definition, for use of that descriptor. What particular way? They exceed the allowable gram of saturated fat per serving.

I have addressed the topic of saturated fat before, more than once, and will spare us any lengthy excursion into those weeds on this occasion. Suffice to say that I agree an excess of saturated fat intake remains a common and relevant concern in the typical American diet, and that FDA rules to help defend against that excess make sense in principle.

But in this case at least, not in practice. The intent of the regulatory language is clearly to guard against the addition of saturated fat per se, as cream, butter, or oil, to a processed food recipe. The pros and cons of that approach could be debated, but it is defensible.

The fat in the KIND bars comes primarily from the nuts, notably almonds, which are a major ingredient. So, for instance, KIND almond and apricot bars have 10 grams of total fat, and 3.5 grams of saturated fat, coming mostly from the first ingredient, almonds, with some fats coming from the second ingredient, coconut (coconut is the primary source of saturated fat in this bar).

This begs the obvious question: If the fat (and saturated fat) in these KIND bars is the reason they can't be called “healthy,” and if this fat (and saturated fat) is entirely, or nearly so, from almonds, does this mean that almonds shouldn't be called “healthy”?

Any such notion is, of course, absurd. There is a voluminous, robust scientific literature (see citations below) showing that almonds, walnuts, and nuts in general confer consistent and quite significant health benefits. Regular intake of nuts has even been associated with a marked reduction in all-cause mortality risk. If that is not the very definition of “healthy” food, I have no idea what could be.

So what's really going on here? The failure of one-size-fits-all-regulation to, in fact, fit all; and the ineluctable law of unintended consequences.

The FDA is a federal agency, and its principal tool is regulatory rules. Dealing with the entire expanse of food and drugs, the FDA tools tend toward the blunt, rather than the surgically sharp. While a numerical threshold for saturated fat as an added ingredient might make some sense, it makes no sense to apply that same regulation to a wholesome, whole food ingredient known to have a healthy overall portfolio of fat content, and decisively good health effects. When almonds, as the first ingredient in a snack, are the reason that snack cannot be called “healthy,” you are well into the realm of unintended consequences. I can pretty much guarantee no such occurrence was envisioned when the regulatory language was drafted.

In addition to nuts, by the way, that same standard threshold for saturated fat would preclude calling hummus, wild salmon, or raw avocado ”healthy.” With all due respect to my friends with the feds, that's, well, nuts.

One more thing to chew on here. Does anyone think that some agent at the FDA with nothing better to do just suddenly, and spontaneously, decided to scrutinize the back of KIND bar packages on the off chance something in the fine print had gone unnoticed? I don't. I have no inside information here, but I can read the writing on the wall, as well as on a food wrapper. KIND has, as noted, grown all but ubiquitous, and for good reason. While such success fosters many claims of friendship, it fosters even more disgruntled adversaries among competitors losing market share to you. I am pretty sure some such party, looking for any way to slow KIND's momentum, legitimate or otherwise, jangled the FDA's chain. I confess it's just conjecture on my part, but ponder as the spirit moves you.

Almonds are, in fact, healthy. Walnuts are healthy. Nuts in general, hummus, and avocado are all healthy. KIND bars, too, made principally from nuts and fruit, are healthy. If a regulation on the books precludes saying so, that doesn't make the statement untrue; it makes the regulation inappropriate as applied.

The regulation, though, is the regulation; and the FDA was just doing its job. I don't think the agency was being ... unkind. I just think they got it wrong.

Health effects of nuts, representative citations:

1: Mohammadifard N, Salehi-Abarghouei A, Salas-Salvadó J, Guasch-Ferré M, Humphries K, Sarrafzadegan N. The effect of tree nut, peanut, and soy nut consumption on blood pressure: a systematic review and meta-analysis of randomized controlled clinical trials. Am J Clin Nutr. 2015 Mar 25. pii:ajcn091595. [Epub ahead of print] PubMed PMID: 25809855.

2: Berryman CE, West SG, Fleming JA, Bordi PL, Kris-Etherton PM. Effects of daily almond consumption on cardiometabolic risk and abdominal adiposity in healthy adults with elevated LDL-cholesterol: a randomized controlled trial. J Am Heart Assoc. 2015 Jan 5;4(1):e000993. doi: 10.1161/JAHA.114.000993. PubMed PMID: 25559009; PubMed Central PMCID: PMC4330049.

3: Jamshed H, Gilani AH. Almonds inhibit dyslipidemia and vascular dysfunction in rats through multiple pathways. J Nutr. 2014 Nov;144(11):1768-74. doi: 10.3945/jn.114.198721. Epub 2014 Sep 24. PubMed PMID: 25332475.

4: Abazarfard Z, Salehi M, Keshavarzi S. The effect of almonds on anthropometric measurements and lipid profile in overweight and obese females in a weight reduction program: A randomized controlled clinical trial. J Res Med Sci. 2014 May;19(5):457-64. PubMed PMID: 25097630; PubMed Central PMCID: PMC4116579.

5: Ukhanova M, Wang X, Baer DJ, Novotny JA, Fredborg M, Mai V. Effects of almond and pistachio consumption on gut microbiota composition in a randomized cross-over human feeding study. Br J Nutr. 2014 Jun 28;111(12):2146-52. doi: 10.1017/S0007114514000385. Epub 2014 Mar 18. PubMed PMID: 24642201.

6: Ley SH, Hamdy O, Mohan V, Hu FB. Prevention and management of type 2 diabetes: dietary components and nutritional strategies. Lancet. 2014 Jun 7;383(9933):1999-2007. doi: 10.1016/S0140-6736(14)60613-9. Review. PubMed PMID:24910231.

7: Jackson CL, Hu FB. Long-term associations of nut consumption with body weight and obesity. Am J Clin Nutr. 2014 Jul;100 Suppl 1:408S-11S. doi: 10.3945/ajcn.113.071332. Epub 2014 Jun 4. PubMed PMID: 24898229; PubMed Central PMCID: PMC4144111.

8: Luo C, Zhang Y, Ding Y, Shan Z, Chen S, Yu M, Hu FB, Liu L. Nut consumption and risk of type 2 diabetes, cardiovascular disease, and all-cause mortality: a systematic review and meta-analysis. Am J Clin Nutr. 2014 Jul;100(1):256-69. doi: 10.3945/ajcn.113.076109. Epub 2014 May 21. PubMed PMID: 24847854.

9: Bao Y, Han J, Hu FB, Giovannucci EL, Stampfer MJ, Willett WC, Fuchs CS. Association of nut consumption with total and cause-specific mortality. N Engl J Med. 2013 Nov 21;369(21):2001-11. doi: 10.1056/NEJMoa1307352. PubMed PMID: 24256379; PubMed Central PMCID: PMC3931001.

10: Toledo E, Hu FB, Estruch R, Buil-Cosiales P, Corella D, Salas-Salvadó J, Covas MI, Arós F, Gómez-Gracia E, Fiol M, Lapetra J, Serra-Majem L, Pinto X, Lamuela-Raventós RM, Saez G, Bulló M, Ruiz-Gutiérrez V, Ros E, Sorli JV, Martinez-Gonzalez MA. Effect of the Mediterranean diet on blood pressure in the PREDIMED trial: results from a randomized controlled trial. BMC Med. 2013 Sep 19;11:207. doi: 10.1186/1741-7015-11-207. PubMed PMID: 24050803; PubMed Central PMCID: PMC3849640.

11: Pan A, Sun Q, Manson JE, Willett WC, Hu FB. Walnut consumption is associated with lower risk of type 2 diabetes in women. J Nutr. 2013 Apr;143(4):512-8. doi: 10.3945/jn.112.172171. Epub 2013 Feb 20. PubMed PMID: 23427333; PubMed Central PMCID: PMC3738245.

12: Katz DL, Davidhi A, Ma Y, Kavak Y, Bifulco L, Njike VY. Effects of walnuts on endothelial function in overweight adults with visceral obesity: a randomized, controlled, crossover trial. J Am Coll Nutr. 2012 Dec;31(6):415-23. PubMed PMID: 23756586; PubMed Central PMCID: PMC3756625.

13: Ma Y, Njike VY, Millet J, Dutta S, Doughty K, Treu JA, Katz DL. Effects of walnut consumption on endothelial function in type 2 diabetic subjects: a randomized controlled crossover trial. Diabetes Care. 2010 Feb;33(2):227-32. doi: 10.2337/dc09-1156. Epub 2009 Oct 30. PubMed PMID: 19880586; PubMed Central PMCID: PMC2809254.

14: Trichopoulou A, Bamia C, Trichopoulos D. Anatomy of health effects of Mediterranean diet: Greek EPIC prospective cohort study. BMJ. 2009 Jun 23;338:b2337. doi: 10.1136/bmj.b2337. PubMed PMID: 19549997; PubMed Central PMCID: PMC3272659.

15: Allen LH. Priority areas for research on the intake, composition, and health effects of tree nuts and peanuts. J Nutr. 2008 Sep;138(9):1763S-1765S. PubMed PMID: 18716183.

16: Jiang R, Manson JE, Stampfer MJ, Liu S, Willett WC, Hu FB. Nut and peanut butter consumption and risk of type 2 diabetes in women. JAMA. 2002 Nov 27;288(20):2554-60. PubMed PMID: 12444862.

17: Luu HN, Blot WJ, Xiang YB, Cai H, Hargreaves MK, Li H, Yang G, Signorello L, Gao YT, Zheng W, Shu XO. Prospective Evaluation of the Association of Nut/Peanut Consumption With Total and Cause-Specific Mortality. JAMA Intern Med. 2015 Mar 2. doi: 10.1001/jamainternmed.2014.8347. [Epub ahead of print] PubMed PMID: 25730101.

Punished for precision (or, too much information from the micro lab!)

We recently had a patient's blood culture turn positive for a Gram-positive, catalase-positive, facultative diphtheroid. In the “pre-matrix-assisted laser desorption/ionization (MALDI)” era, we'd have called this isolate a “diphtheroid.” Taking into account other aspects of the case, the National Healthcare Safety Network (NHSN) definition would have categorized this as a contaminant (diphtheroids being on the “common commensal” list maintained by NHSN). By virtue of the wonders of mass spectrometry, we are now able to identify the organism to species-level as Actinomyces neuii, an organism previously categorized as CDC group 1-like coryneform bacteria (also on the “common commensal” list).

A. neuii isn't anywhere on the NHSN organism lists. However, Actinomyces species (as a group) can be found on the “all organisms” list but NOT on the “common commensal” list. The NHSN rules tell us we have to categorize any organism on the “all organisms” list that isn't also on the “common commensals” list as a pathogen, meaning this positive blood culture now helps define a central-line associated bloodstream infection (CLABSI).

And that's the story of how a contaminated blood culture became a CLABSI. We've had other similar cases since we introduced MALDI-time of flight (TOF). Before the CLABSI rate became worth millions of dollars to a hospital's bottom line and reputation, this might have been easy to navigate. Now, though, it's a much bigger deal.

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. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Wednesday, May 20, 2015

Pneumonia prevention bundle in nursing homes: a cluster-randomized trial

If you're looking for another infection prevention bundle in long-term care, look no further than the March 15 issue of Clinical Infectious Diseases that included a cluster-randomized trial of a pneumonia prevention bundle in 36 Connecticut nursing homes by Juthani-Mehta and colleagues at Yale (full text free). Residents in the intervention nursing homes with at least 1 risk factor (impaired oral hygiene or swallowing difficulty) received a bundle that included manual tooth/gum brushing plus 0.12% chlorhexidine oral rinse, twice per day, plus upright positioning during feeding.

The primary outcome was development of first pneumonia defined as “presence of (1) a compatible infiltrate on chest radiograph (CXR) (if previous CXR was available, the infiltrate had to be new or worsened) and (2) at least 2 of the following clinical features within 72 hours of the CXR-documented infiltrate: fever, pleuritic chest pain, respiratory rate over 25 breaths/minute, worsening functional status (ie, decline in level of consciousness or activities of daily living), or new or increased cough, sputum production, shortness of breath, or chest examination findings.” The secondary outcome was first lower respiratory tract infection (LRTI).

After enrolling 834 participants (434 to the intervention arm and 400 to the control arm), the data safety monitoring board terminated the study for futility. Results showed no significant differences for cumulative incidence of first pneumonia or first LRTI between intervention and control arms. In fact, you can see in the study that that the intervention arm appears to have higher incidence of first pneumonia, which is concerning.

Of note, adherence was 87.9% to chlorhexidine, 75% to toothpaste and 100% for upright feeding position in the intervention facilities. The authors offer several explanations for the study's failure, none of which are entirely convincing. For example, adherence at these levels should have still shown some benefit and not a trend toward harm, so it's unlikely that compliance explains the results. For those interested in reading more, there is an excellent commentary by Lona Mody. Congratulations to the authors and journal for publishing this important negative study.

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.
Tuesday, May 19, 2015

Doctor, don't treat yourself, or family members

The day I started medical school, I called home to tell my parents about it. My mother, a hypochondriac, didn't want to hear about the class schedule or the amount of work.

“I have a new rash I need you to take a look at,” she told me.

What did she think? That after one day, I'd suddenly been imparted all the knowledge I'd need to treat her? (As you'll see later, I would come to wish that had happened.)

Silly Mom. As if I'd been admitted to some special club.

This comes up more often than you might think in medical practice. The ethics are fairly clear — it's not illegal to treat family members or friends, but it's unethical because those friends and family members cannot exercise their full autonomy when making medical decisions.

Just published on NPR's Shots blog is a column I wrote about our experience caring for our daughter during this past winter's flu season, and a couple of stories of familial ethical challenges from other doctors. Please click over and take a look. Thanks to Katherine Streeter for great collage art.

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.

Whose record is it?

A recent piece in the New York Times profiled a young man with a remarkable medical history, and an equally remarkable approach to sharing it. I think it raises some profound issues regarding the self-monitoring movement and the “ownership” of patients' health information, both of which have the potential to change our traditional practices in a big way.

The guy, Steven Keating, is not your average Joe. He is a graduate student at MIT who trained as a mechanical engineer and is working in the cutting-edge MIT Media Lab. He also had a brain tumor the size of a tennis ball. His website hosts all of his medical records, including his pre- and post-op brain scans and, believe it or not, a video of his tumor resection surgery.

The article described the struggle that he had in assembling all of his records, which obviously had nothing to do with his technical skills, and everything to do with the sorry state of medical records, electronic or otherwise. Despite the fact that federal law recognizes that patients be provided with “their” records, we have traditionally behaved as if the records are ours, and we are doing patients a big favor by “sharing” them. The challenge for patients is compounded by the generally poor capability of present-day EMRs and storage systems to share data. Of course, this “design feature” just reflects (and thereby helps preserve) the attitude that the data belongs to the doctors and hospitals, and not the patients. Ready or not, that attitude has to change.

First, we no longer have a monopoly on generating the data. In an era where patients have access to monitoring devices and increasingly sophisticated sensors, and apps that can store, track and analyze their output, we will be asking patients for their test results, not the other way around. This is the premise behind Eric Topol's new book, The Patient Will See You Now. I have already been emailed an ECG rhythm strip by one of my patients that he took himself using a sensor that snaps onto the back of an iPhone . In that world, it makes no sense to pretend that the tracing is “mine.” It is not; it is his, and he chose to share it with me.

Second, I really think we have reached a tipping point in terms of what patients will tolerate. In a world where I can pay all my bills electronically, get a download of all of my Amazon purchases from the last year, make a dinner reservation through OpenTable, and even file my taxes electronically, how much longer do you think patients will be willing to fax release forms and get paper copies of some unreadable EMR notes, or poor quality photocopies of low-resolution print-outs of some imaging study, and then schlep them across town so we can scan them into a different electronic system?

I think we had better get cracking to meet the growing demands of our patients to help them interpret the data they already have, and to surrender control of what we have to them.

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.
Monday, May 18, 2015

Are CT scans accurate for diagnosing cancer?

A female patient came to see me with some difficulty swallowing, a very routine issue for a gastroenterologist. I performed a scope examination of her esophagus and confronted a huge cancer occupying the lower portion of her esophagus.

I expected a benign explanation for her swallowing issue. She was relatively young and not particularly ill. She had seen my partner years in the past for a similar complaint, which he effectively treated by stretching her esophagus. I expected that I my procedure would be a re-run. I was wrong.

Prior to the procedure, we chatted and I learned that she had recently undergone a CT scan of the chest ordered in response to some respiratory symptoms, which were not severe. After I had completed my scope examination of her, I was amazed that no mention of this tumor was related to the patient, who had told me that only a hiatal hernia was seen.

I requested a fax of the report which confirmed that the radiologist made no mention of an esophageal abnormality. I assumed that this scan was not interpreted properly by the radiologist who somehow missed this large, consequential mass in the esophagus. Fortunately, this error caused no harm as I found the cancer just 2 weeks later.

I called the senior radiologist at the hospital as I wanted him to review the scan and to implement whatever internal quality control procedures that existed. I would want the same effort expended if I had missed a lesion or committed a medical error. He reviewed the scan he agreed with the original radiologist's interpretation. He explained to me how in this case the tumor appeared just like a benign hiatal hernia. If any reader is suspected that this guy is just covering for her colleague, I verify that this is not the case. The radiologist I called is irreproachable.

Usually, we face the opposite scenario from radiologist. They find lesions everywhere that are benign, but send patients and their doctors on cascade into chaos.

I believe that the cancer, which developed in such a stealth fashion in my patient, also hid from the radiologist.

My point here for patients is that scans are imperfect. They can miss stuff that matters and uncover stuff that means nothing, the more common outcome. It's a reminder that the practice of medicine is imperfect and offers no guarantees even when it is performed well. This vignette reminds me how important it is to listen carefully to the patient. The scans, labs and even the colonoscopies might be wrong.

If I'm worried about a patient, but the data all scream that he is healthy, should I relax? If a patient feels superb, but the scan shows something found by accident, do I sharpen up the scalpel?

I am gastroenterologist. I prefer to go with my gut.

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.

What doctors can learn from Uber drivers

A couple of months ago I finally joined the swelling ranks of Uber customers. Several friends had been trying to persuade me for some time to start using the service, but me being generally skeptical of new technology (what they call a “late adopter”), it took an extreme situation to get me to finally download the app. It was a freezing February evening and I was just getting home from work. Boston had experienced yet another severe snowstorm and there was a parking ban in effect. I drove around my neighborhood for some time, and there was absolutely nowhere to park. Frustrated, I took the decision to drive to a nearby garage and leave my car there for the next few days. I was sick of shoveling and clearing the snow off my car every morning, and with even more snow forecast, I decided that I would just use alternative transportation to get to and from hospital until the weather eased a little. So when I got home that night I did it: I made the decision to download Uber onto my iPhone.

The following morning I used their screen interface and tracking system (which is slick, user-friendly and overall excellent) to hail my first Uber driver. They were outside my house in a matter of minutes, and dutifully drove me to the hospital in good time. I continued to use Uber for the rest of that week, until finally it was okay to get my car back. I was absolutely blown away by the service I got and since that time have been using them regularly in at least a couple of different cities.

More than the actual service, I have also been highly impressed with the Uber drivers themselves. Perhaps I am lucky or perhaps Boston attracts a different category of drivers, but I've met some really interesting people on my car journeys. Some of them have other full-time jobs (including in health care), some are still in school, and some are budding entrepreneurs who were starting up side businesses. I've been driven by men and women of all ages and backgrounds.

No disrespect to regular taxi drivers, but the conversations I've had with Uber drivers in the last 2 months have been far more interesting than the ones I've had with regular cab drivers over the last several years. They've told me stories about what brought them to driving with Uber and how the process works to get registered, have background checks, and then determine their own work schedule. There's also another common theme that emerges: Uber drivers absolutely love what they do. They enjoy the fact that they work on their own terms and are free to earn as much or as little as they like. They are independent contractors and feel in control of their schedule. Most of all I've heard they really enjoy being their own boss and not being told what to do and when to do it. Lots of them work very long hours, averaging 12 hours a day of driving, but were choosing to do so. Nearly all the drivers were educated (and heck, some of the cars I've been transported in have been high-end luxury models) and had high hopes and aspirations. One thing they would never do: be a regular employed taxi driver.

So how does this tie into doctors and health care? Well, the last decade has seen relentless consolidation and amalgamation, with the majority of physicians moving towards a standard “employee” model. The days of the small group practice and solo-practitioner seem numbered. With any perceived improvement in work-life balance or employee benefits that this may bring, also comes a hefty price to pay. Employees will always have less control over their work life. Many things will be dictated from above about what they must and mustn't do. These are the unavoidable parts of being an employee that suck. But that's the trade-off.

The happiest physicians I still see are the ones who are in their own small practice and have not yet been taken over by a larger group. They may work harder (like any entrepreneur) but they wouldn't have it any other way. What's more, their patients seem to be happier and more satisfied too (a bit like me with the Uber drivers?). Yet the reality is that consolidation is the direction of healthcare whether we like it or not.

The battles that Uber is fighting with entrenched organizations such as taxi firms are well publicized in the media. One Uber driver told me that there's another big legal battle stating that Uber should ditch the private contractor model to make all Uber drivers “employees” of the company with a salary. When I asked him what he thought of this, his response was a resounding “Hell no!” and he said he would find something else to do if this ever happened. While doctors may be losing the battle for autonomy, I hope that the enterprising and fiercely independent Uber drivers are smart enough not to.

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.
Friday, May 15, 2015

Learning from the detectives

Many readers know that I love mystery novels and TV shows. Recently I was talking with a third-year student, and realized that one of the reasons I love internal medicine is that every day I am a detective. As I watch detective shows and movies and as I read or listen to detective novels I am learning lessons about being a better diagnostician.

The best detectives collect data prior to coming to conclusions. They avoid premature closure. As they look at the evidence they do not act on the obvious, but rather ask about missing data. They refuse to rush to judgment.

The best detectives interview “persons of interest” during their investigation, but when they find more evidence (using from the CSI group) they resume their interviews, asking new questions, building on the scientific evidence.

The best detectives use mind play to consider possibilities. They tell a story (either out loud, or in their minds) and in the telling test that story for inconsistent data.

The best detectives obsess, not willing to give up on finding the answer. They keep searching until the answer becomes crystal clear.

Could you substitute “the best internists” in the above paragraphs?

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.
Thursday, May 14, 2015

Exercise: the luminous, latent potential of a little action

Mechanistically, exercise is entirely dependent on action potentials, while its incredible benefits may be characterized as the potential of action to enhance our lives. Ironically, perhaps, the luminous potential of action to promote our health is in a very fundamental way the exact opposite of the action potentials from which it derives.

I imagine that may be about as clear as the way through a Tough Mudder. No worries; I've got Windex.

An action potential refers to the mechanism that underlies the firing of our nerve cells, or neurons. Famously, action potentials are “all or nothing.”

At rest, there is a slight electrical gradient maintained across the cell membrane of a neuron. That slight charge is energy dependent, requiring the constant work of ion channels that traverse the cell membrane, shuttling positively and negatively charged ions in opposite directions. When we talk about “resting energy expenditure,” or “basal metabolism,” these are the kinds of functions represented; our cells are always working even when we are not.

That electrical gradient is, quite literally, an “action potential,” because it primes the cell to take the one action it owns: depolarizing. When a stimulus reaches a neuron, if it is strong enough, it reverses the electrical charge at the site of contact. That reversal of charge, or depolarization, then courses along the length of that nerve cell, rather like a fast moving wave.

If the nerve cell in question is a sensory neuron, the result of that wave is that we feel or perceive something, a caress, a color, a shiver, or a symphony. If it is a motor neuron, it ends at a muscle cell, which in turn is stimulated to contract. When a whole lot of muscle cells contract in unison, we have the familiar command over our moving body parts; such as my fingers, currently dancing over this keyboard.

We could, of course, go much deeper into the weeds, but that's the relevant gist. What matters for today's story is that the depolarization of every neuron, or muscle cell (myocyte) for that matter, is all or nothing. The stimulus reaching it is either enough to excite full depolarization, or it is not. There are no partial responses; there is no dose response curve*.

Exercise is just the opposite. There is an enormous benefit from even a little, more benefit from more, and then a threshold past which returns diminish, but don't decline. The take-away message is that there is enormous potential for even a little bit of action to make our health, and lives, better.

We have long known this, frankly. It is the reason why prevailing recommendations for physical activity rally around 30 minutes or so, roughly 5 days out of every 7. That's not really very much for a species that spent millennia as roaming bands of hunter-gatherers. It is, however, enough to generate decisive health benefits in an age when the clan is a distant memory, and the couch a constant temptation.

A new study reaffirms this. Just published on-line in JAMA Internal Medicine, the paper explores the relationship between weekly, average exercise and mortality in more than 650,000 men and women. The findings confirm our convictions, and validate our fervent hopes, about motion.

The risk of dying prematurely was reduced 20 percent in those who did “any” routine physical activity, as compared to those who did none. Those how met that recommended minimum of 150 minutes per week of moderate activity had more than a 30 percent reduction in mortality risk. Those who exceeded the minimum by a factor of two to three had a nearly 40 percent mortality reduction. Benefits went up as exercise increased, but they diminished; the mortality benefit was front-loaded.

While the new study looked at benefit in terms of mortality, the real rewards of routine exercise may be even better captured in considerations of morbidity, or its converse- vitality. Lack of habitual motion has long been atop the short list of factors contributing to both premature death, and chronic disease. Conversely, routine activity is a key factor on the short list associated with a lifetime reduction in the risk of all chronic diseases of roughly 80 percent.

Those of us who are active routinely probably all agree that motion is its own reward. We have vital, animal bodies made to move. Taking them off the leash and out of the cage of modern, sedentary living just feels good. For those who doubt it, a major reduction in the lifelong risk of any major chronic disease is a pretty good, alternative motivation.

Move, because your body was made to move. Move, because you will be less likely to die prematurely. Move, because you will be less likely to succumb to any major chronic disease, and more likely to recover from, or thrive despite, any you already have. Move, because it is vital to health. And strive for health not because I say so, but because healthy people have more fun.

The potential contribution of action to health is quite incredible, and accessible to almost all of us. Unlike the action potential with which it originates, the potential of action is considerable with even the first little bit; some is much better than none.

I invite and encourage you on that basis to take action; any kind, and any amount- and share the notion of motion with those you love. The luminous potential of it is at your disposal. Exploit it, and live a life likely to be both longer, and better.

*You may be wondering: how can we differentiate strong and weak signals, a caress from a smack, a whisper from an explosion- if our neuronal response is all or none? The answer is: it depends on the number, and variety, of neurons that get in on the action.

The response of any given neuron is all or none. However, the number of neurons activated does vary with the strength of the stimulus. Equally important, we have both excitatory neurons, that enhance our perception of a stimulus, and inhibitory neurons that dampen it (one of the more important functions of our nervous system is to squelch our awareness of superfluous stimuli bombarding us all the time). A strong stimulus will tend to overcome inhibitory neurons, whereas they will prevail when the signal is weaker.

The balance between these Yin and Yang forces of neurology also changes with circumstance. For example, when you first put on your underwear today, you were quite conscious of the slight pressure of that elastic band against your skin. Until I made you think of it just now, however, you were entirely unconscious of it (if you are not wearing underwear, I don't want to know about it ...). That's because the signal in question is only useful to indicate a “change” in our condition; it is not of much use as continuous input over the course of our day. So, thankfully, the nervous system squelches it, and we are free to think loftier thoughts than: Yep, I've still got my underwear on!

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.