Medical News Today
- Anxiety Disorders And Cellular Metabolism Linked Researchers at the University of Chicago have found an association between anxiety disorders and the gene that encodes Glyoxylase 1 (GLO1). However, the mechanism underlying this association is unclear. The most prevalent psychiatric diseases in the United States are anxiety disorders, which range from post-traumatic stress disorder to social phobia. Using a mouse model, Margaret Distler and her team set out to determine whether the primary substrate of GlO1, methylglyoxal, might have unproven neurological effects...
- Hunger Among Seniors In The USA Rose 78% In Ten Years 8.3 million (14.85%) seniors in the United States face the threat of hunger, say researchers at the University of Illinois. From 2001 to 2010, the incidence of hunger among seniors has risen by 78%, and by 34% since the onset of the recession in 2007. Craig Gundersen, University of Illinois associate professor of agricultural and consumer economics and executive director of the National Soybean Research Laboratory, said: "In 2005, we reported that one in nine seniors faced the threat of hunger...
- Athlete's High Pain Threshold May Help Pain Management Re... Athletes are often seen to put on a 'brave face and carry on' when they sustain an injury, which supports the theory that they have a higher pain threshold than non-athletes, regardless of inconsistent and sometimes even contradictory evidence from previous studies on pain perception in athletes...
- Drug Approval Faster In US FDA Than Its European Or Canad... Although the drug approval process in the U.S. has been perceived as too slow, the nation approves new drug treatments faster and earlier than Europe and Canada, according to researchers at Yale School of Medicine. The study, conducted by Nicholas Downing, a second-year medical student and Joseph S. Ross, M.D., assistant professor of internal medicine at Yale School of Medicine, found that the median total time to review was: 322 days at The U.S...
- Running Marathons - Death Risk Low, Higher Among Men In recent years, the popularity of marathons has grown significantly and although the risk of dying during a marathon or soon after is extremely low - about 0.75 per 100,000 - men are two times more likely to die than women, say researchers at John Hopkins University School of Medicine. In addition, the number of individuals to complete grueling 26.2 mile marathons in the United States increased dramatically between 2000 and 2009, from 299,018 to 473,354. The study is published online in The American Journal of Sports Medicine. Julius Cuong Pham, M.D., Ph.D...
- Reducing Booze Consumption Better For Public Health And E... According to a new study in the American Journal of Public Health, Australia could yield economic and health benefits by reducing its overall national yearly alcohol consumption. In 2008, researchers estimated the economic benefits Australia could achieve in health, production and leisure, if the annual per capita consumption of alcohol would be reduced to a designated average yearly target of 6.4 liters per capita. They discovered that reducing the annual per capita alcohol consumption by just 3.4 liters would save Australia's health sector $789 million...
- Diabetes Population May Rise To 53 Million Within 13 Year... By the year 2025, researchers predict that 53.1 million individuals in the United States will have diabetes (mainly type 2 diabetes) - a 64% increase from 2010. The study is published in Population Health Management Diabetes is a life long disease in which there are high levels of glucose in the blood. In type 1 diabetes the body does not produce insulin and in type 2 diabetes the body either produces insufficient amounts of insulin or ignores it. William Rowley, M.D., and Clement Bezold, Ph.D...
- Fighting Multidrug-Resistant Bugs - Last Resort Drugs Bei... A study published in the open access journal PloS ONE reveals that the use of "last resort" antibiotics is on the rise due to the increasing prevalence of multidrug-resistant pathogens. Makoto Jones, of the Veterans Affairs Salt Lake City Health Care System, and colleagues conducted the study in order to investigate the use of two such antibiotics, tigecycline and polymyxins, in 127 Veterans Affairs Medical centers between 2005 and 2010. The researchers found that 26 centers accounted for 75% of all tigecycline use, and just 8 centers accounted for 75% of all polymyxin use...
- Strict School Physical Education Laws Improve Children's ... As childhood obesity and diabetes rates are skyrocketing in the US, many schools are eliminating physical education classes. A national study in the American Journal of Public Health reports that specific and required state legislation with regard to PE times could be a crucial tool to ensure that children meet the daily recommendations of physical activity...
- Heart Healthier Oat Variety Developed Plant breeders of the Wisconsin-Madison University have developed a new oat variety called BetaGene, which is 2% higher in beta glucan and therefore even more cardio-friendly than other oat varieties on the market. John Mochon, program manager of the Small Grains Breeding Program in UW-Madison's agronomy department explains: "The biggest thing that stands out about this new variety, BetaGene, is that it's both a high yielding variety and high in beta glucan. Beta glucan is a heart-healthy chemical that is exclusive to oats...
Newswise: MedNews
- UCLA Medical Group Receives Two Prestigious Awards The UCLA Medical Group was recently recognized by both the California Association of Physician Groups and the National Committee for Quality Assurance for its outstanding patient-centered care and medical care management.
- UNC Charlotte to Offer World's First Neurodiagnostics and... UNC Charlotte will offer the world's first bachelor's degree in neurodiagnostics and sleep science (NDSS). This innovative, online degree will be available through the College of Health and Human Service's Kinesiology Department in collaboration with UNC-Chapel Hill's Department of Allied Health Sciences. The program will accept students starting with the fall 2012 semester.
- Research Project for Blood Transfusions in Trauma Patient... Researchers at The University of Texas Health Science Center at Houston (UTHealth) are launching a new research study to find the best way to give blood transfusions for severely injured patients predicted to require massive blood transfusions upon arrival to the Memorial Hermann-Texas Medical Center emergency department. Bryan Cotton, M.D., of UTHealth is principal investigator for this clinical study.
- Nurse Practitioner-Driven Palliative Care Intervention Im... Recent studies have shown that palliative care interventions aimed at addressing patients' emotional, spiritual and social needs have a significant impact on cancer patients' quality of life and may even improve cancer patients' overall survival.
- Comprehensive Report Documents Impact of Urologic Disease... Urologic conditions like urinary tract infections, kidney stones, and prostate cancer are a major economic burden on Americans, resulting in health care costs of close to $40 billion annually, according to a newly released national report that charts the demographic and economic impact of urologic diseases in the U.S.
- Loyola Lactation Consultant Reacts to Report on Toxins in... When writer Florence Williams was nursing her second child, she had her breast milk analyzed for toxins. What she found surprised her. Trace amounts of pesticides, dioxin, a jet-fuel ingredient and high-to-average levels of flame retardants were present in her breast milk. She reported on these findings in New York Times Magazine, which has since set off a wave of controversy. A Loyola University Health System lactation consultant puts these findings in perspective.
- People with Asthma Get the Green Light for Exercise Not only is it safe for people with asthma to exercise, but doing so could reduce their risk of asthma symptoms or attacks, according to a new evidence review in The Cochrane Library.
- Doctors Need Training to Help Smokers Quit Health care professionals do a better job helping people quit smoking when they are trained in smoking cessation techniques, a new Cochrane Library review finds.
- Multipotent Stromal Stem Cells from Normally Discarded Hu... Scientists at Children's Hospital Oakland Research Institute (CHORI) led by Vladimir Serikov, MD, PhD, and Frans Kuypers, PhD, report in the current Epub issue of Stem Cells Translational Medicine that placental stem cells with important therapeutic properties can be harvested in large quantities from the fetal side of human term placentas (called the chorion). The chorion is a part of the afterbirth and is normally discarded after delivery, but it contains stem cells of fetal origin that appear to be pluripotent -- i.e., they can differentiate into different types of human cells, such as lung, liver, or brain cells. Since these functional placental stem cells can be isolated from either fresh or frozen term human placentas, this implies that if each individual's placenta is stored at birth instead of thrown away, these cells can be harvested in the future if therapeutic need arises. This potential represents a major breakthrough in the stem cell field.
- Phase I Clinical Trial Shows Drug Shrinks Melanoma Brain ... Three-pronged study reveals high response rate in other advanced melanoma patients and activity in multiple cancers.
ScienceDaily: Health & Medicine News
- 'Rare' genetic variants are surprisingly common, life sci... A large survey of human genetic variation shows that rare genetic variants are not so rare after all, and offers insights into human diseases. A team of scientists studied 202 genes in 14,002 people -- one of the largest ever in a sequencing study in humans.
- How exercise affects the brain: Age and genetics play a role Findings suggest that the effects of exercise on memory depend on the age of the exerciser; underlying genetic mechanisms matter, too.
- New key mechanism in cell division discovered Researchers have identified the mechanism by which protein Zds1 regulates a key function in mitosis, the process that occurs immediately before cell division. The research opens the door to developing targeted and direct therapies against cancer.
- Sutureless aortic valve replacement a North American first A surgical milestone was reached on May 1st with a sutureless aortic valve replacement through a thoracic incision just 5 centimeters long. The two patients in their seventies who underwent this innovative procedure were doing well only one week after their operations.
- Phase I clinical trial shows drug shrinks melanoma brain ... An experimental drug targeting a common mutation in melanoma successfully shrank tumors that spread to the brain in nine out of 10 patients in part of an international phase I clinical trial report.
- Google goes cancer: Search engine algorithm finds cancer ... The strategy used by Google to decide which pages are relevant for a search query can also be used to determine which proteins in a patient's cancer are relevant for the disease progression.
- Slew of rare DNA changes following population explosion m... Scientists have taken a first step toward understanding how rare genetic differences among people contribute to leading chronic illnesses. One-letter DNA code changes occur frequently in human genomes, but each variant is usually found in only a few individuals. This phenomenon is consistent with the population explosion of the past 5,000 years. Studying the evolution of rare genetic variants and their health impact is critical as low cost, rapid sequencing enters clinical use. Such information would help doctors interpret personal genomes.
- Babies' susceptibility to colds linked to immune response... Innate differences in immunity can be detected at birth, according to new research. And babies with a better innate response to viruses have fewer respiratory illnesses in the first year of life.
- Prosthetic retina offers simple solution for restoring sight A device which could restore sight to patients with one of the most common causes of blindness in the developed world is being developed.
- Suspicion resides in two regions of the brain: Our baseli... Scientists have found that suspicion resides in two distinct regions of the brain: the amygdala, which plays a central role in processing fear and emotional memories, and the parahippocampal gyrus, which is associated with declarative memory and the recognition of scenes.
Health News Headlines - Yahoo! News
- 'Good' cholesterol doctrine may be flawed: study Researchers on Thursday challenged a tenet of modern medicine that higher levels of "good" cholesterol automatically boost cardiovascular health.
- Minorities overtake whites in US births For the first time ever, white births in the United States are no longer in the majority, according to US Census Bureau estimates Thursday that underscored the growth of the Hispanic population.
- Common antibiotic boosts death risk: study A popular antibiotic used for treating bronchitis, pneumonia, ear infections and sexually transmitted diseases may boost the risk of death, a US study said Wednesday.
- CDC to baby boomers: Get tested for hepatitis C For the first time, the government is proposing that all baby boomers get tested for hepatitis C.
- French autistic kids mostly get psychotherapy In most developed countries, children with autism are usually sent to school where they get special education classes. But in France, they are more often sent to a psychiatrist where they get talk therapy meant for people with psychological or emotional problems.
- Panel debates bioterrorism protection for children The Obama administration is asking a presidential commission to help decide an ethical quandary: Should the anthrax vaccine and other treatments being stockpiled in case of a bioterror attack be tested in children?
- Flesh-Eat Victim on Amputations: 'Let's Do This' Aimee Copeland, who lost her leg to a flesh-eating infection after a zip-line injury, learned that she will also lose her right foot and hands.
- Fees Lead Some Kids to Skip After-School Sports: Survey FRIDAY, May 18 (HealthDay News) -- Schools that charge kids to participate in sports may be benching some children, a new survey finds.
- Melanoma a Big Threat to Older Men FRIDAY, May 18 (HealthDay News) -- Older men have an increased risk of developing melanoma, but most are careless about sun protection and do not know how to properly check themselves for signs of skin cancer, a new survey reveals.
- Females, Young Athletes Take Longer to Get Over Concussions FRIDAY, May 18 (HealthDay News) -- Female athletes take longer to recover from concussions, a new study says.
BBC World Health News
- Dieting 'safe for pregnant women' Dieting in pregnancy is safe and does not carry risks for the baby, a review of research has suggested.
- Statins 'benefit healthy people' Thousands of heart attacks and strokes could be prevented if the cholesterol-lowering drugs, statins, were more widely prescribed, research suggests.
- Father wants 'donation' lessons A father who lost his son to leukaemia is calling for schools and colleges to make a lesson on donating stem cells, blood and organs part of the curriculum.
- UK retains strict animal test law The UK says it will retain stricter animal testing standards than required by a new European Union Directive.
- White births now minority in US Children from racial and ethnic minorities now account for more than half the births in the US, estimates from the latest census data say.
- Oldest living kidney donor at 83 An 83-year-old man becomes the oldest person in the UK to donate a kidney while still alive, the NHS Blood and Transplant service says.
- Robotic arm controlled by thought Two patients who are paralysed from the neck down are able to control a robotic arm using their thoughts.
- Old films to aid memory recovery Old home movies are being used to help trigger the forgotten past of people with dementia and other memory loss.
- Cannabis laws 'need changing' Growing small amounts of cannabis should be treated like a speeding ticket with a fine and no criminal record, according to a drugs charity.
- Home HIV tests backed by US panel Over-the-counter HIV tests, which would allow people in the US to check in the privacy of their homes if they have the virus, move a step closer.
MedPageToday Headlines
- Lab Notes: Sugar Sours Memory, Fish Oil Trumps (MedPage Today) -- Rats fed a sugary diet forgot how to run a maze they had previously mastered, but the effect was countered by omega-3 fatty acid supplements. Also this week: new hope for Fanconi anemia.
- Genetic Testing May Not Drive Up Health Costs (MedPage Today) -- Having the results of a personalized genetic test did not drive patients to utilize potentially costly follow-up healthcare services, a study from the National Institutes of Health (NIH) found.
- PodMed: A Medical News Roundup from Johns Hopkins (with a... (MedPage Today) -- This week's topics include stress testing after heart procedures, coffee and mortality, air pollution and markers of inflammation, and laxative-free colonoscopy.
- Biodegradable Stents Hold Up (CME/CE) (MedPage Today) -- The next generation of drug-eluting stents that do a disappearing act, whether with a biodegradable polymer or an entirely bioabsorbable platform, appears to be holding up to conventional stents over the short term.
- Diabetic Nerve Damage Linked to Metabolic Factors (CME/CE) (MedPage Today) -- Targeting the various aspects of the metabolic syndrome may provide a means for preventing the development of diabetic neuropathy, authors of a review suggested.
- 'Parachute' Promising for Heart Failure (CME/CE) PARIS (MedPage Today) -- A percutaneous device that walls off part of the left ventricle to help failing hearts appears to have a big impact on outcomes, pilot study results showed.
- Glitazones Take New Hit for Bladder Ca Risk CHICAGO (MedPage Today) -- British patients followed after starting on glitazone drugs for type 2 diabetes were significantly more likely to develop bladder cancer than those taking sulfonylurea agents.
- CDC: Test All 'Boomers' for Hepatitis C Infection ATLANTA (MedPage Today) -- With "baby boomers" believed to account for 75% of the hepatitis C infected population in the U.S. -- the CDC wants everyone ages 47 to 67 be tested for infection.
- Nerve Ablation Safely Lowers BP in CKD (CME/CE) (MedPage Today) -- Catheter-based renal nerve ablation helps lower resistant hypertension, but now researchers have found that it works as well in those with chronic kidney disease, a pilot study showed.
- Bigger BP Drop Goal for Renal Denervation (CME/CE) PARIS (MedPage Today) -- More dramatic blood pressure reductions may be on the horizon for patients with resistant hypertension given the phalanx of renal denervation systems under development.
Reuters: Health News
- California teens eat fewer calories in school NEW YORK (Reuters Health) - High school kids in California, a state that limits the junk food sold in vending machines, eat fewer calories in school than kids in states without such regulations, according to a new study.
- Antibiotics prevent UTIs better than probiotics NEW YORK (Reuters Health) - Antibiotics are still better than probiotics at preventing urinary tract infections, but at least "good bacteria" don't add to a person's antibiotic resistance, a new study concludes.
- Fish oil shows little effect on Tourette's tics NEW YORK (Reuters Health) - Some parents swear by fish oil as a treatment for the "tics" caused by Tourette's disorder, but so far the research evidence is slim.
- Health secretary urges contraception compromise WASHINGTON (Reuters) - The Obama administration's top health official on Friday took the debate over whether healthcare coverage should include contraceptives to the campus of a Catholic university that has been deeply divided over the administration's policy.
- All baby boomers should get hepatitis C test -CDC (Reuters) - All baby boomers should be tested at least once for the liver-destroying hepatitis C virus, according to proposed guidelines from U.S. health officials released on Friday.
- Study unpicks gene changes behind breast cancer LONDON (Reuters) - Scientists have mapped the complete genetic codes of 21 breast cancers and created a catalogue of the mutations that accumulate in breast cells, raising hopes that the disease may be able to be spotted earlier and treated more effectively in future.
- Exclusive: Drugmakers weigh emergency supply plan for Greece LONDON (Reuters) - International drugmakers are working with European authorities on emergency plans to keep medicines flowing into Greece if the country crashes out of the euro.
- New York judge with cancer makes case for marijuana NEW YORK (Reuters) - A cancer-stricken judge in New York has become an unlikely voice in support of legalizing the use of medical marijuana with the admission that he smokes pot to ease the side-effects of his treatments.
- Sex, age may affect athletes' concussion recovery NEW YORK (Reuters Health) - Female and high school athletes may need more time to recover from a concussion than their male or college counterparts, a new study finds.
- Many pregnant women may not get STD tests NEW YORK (Reuters Health) - Despite recommendations that pregnant women have tests for certain sexually transmitted diseases, many may not be getting them, a new study suggests.
Medscape Headlines
- Lead Size, Venous Occlusion Found UnrelatedLead Size, Ven... Is it time to rethink the slimming of pacing and ICD leads? Thinner may not be better for a number of reasons, and one of its supposed advantages may be a myth. Heartwire
- New Renal-Denervation Systems Debut Amid Excitement, Caut... denervation -- poised to depose TAVI as the hottest thing in interventional cardiology -- had its own color-coded track in EuroPCR 2012 this year. Heartwire
- Extended-Release Hydromorphone Fails in Osteoarthritis Tr... Extended-release hydromorphone could not relieve osteoarthritis pain any better than placebo in a phase 3 trial. Medscape Medical News
- What's Hot at AUA 2012?What's Hot at AUA 2012? Here are some of the highlights and offerings of the upcoming meeting. Medscape Medical News
- Strokes Down in New TAVI AnalysesStrokes Down in New TAVI... Two registries and one meta-analysis presented Thursday at EuroPCR point to 30-day major stroke rates ranging from 1.2% to 2.9% in two of the studies. Heartwire
- Mental Illness Not Always Behind Outrageous CrimesMental ... The idea that people who commit outrageous crimes are always mentally ill and that psychiatrists often 'get them off' is a misconception, says a UK psychiatrist looking into the Anders Breivik case. Medscape Medical News
- CDC Proposes HCV Testing for All Baby BoomersCDC Proposes... The US Centers for Disease Control and Prevention has proposed expanded recommendations for a 1-time hepatitis C virus test for all baby boomers. Medscape Medical News
- American Pain Society (APS) 31st Annual Scientific Meetin... Read clinically focused news coverage of key developments from the meeting. Medscape Neurology
- Prevalence of NAFLD Increasing Among American Adolescents... Rising rates of obesity do not explain the increase. Medscape Medical News
- Parasite Linked to Suicidality in Schizophrenia PatientsP... The Toxoplasma gondii antibody may be a biomarker for suicidal behavior in younger adult patients with schizophrenia. Medscape Medical News
AP Health News
- CDC to baby boomers: Get tested for hepatitis C ATLANTA (AP) -- For the first time, the government is proposing that all baby boomers get tested for hepatitis C....
- French autistic kids mostly get psychotherapy LONDON (AP) -- In most developed countries, children with autism are usually sent to school where they get special education classes. But in France, they are more often sent to a psychiatrist where they get talk therapy meant for people with psychological or emotional problems....
- Panel debates bioterrorism protection for children WASHINGTON (AP) -- The Obama administration is asking a presidential commission to help decide an ethical quandary: Should the anthrax vaccine and other treatments being stockpiled in case of a bioterror attack be tested in children?...
- Fate of 'uninsurables' hinges on Supreme Court WASHINGTON (AP) -- Cancer patient Kathy Watson voted Republican in 2008 and believes the government has no right telling Americans to get health insurance. Nonetheless, she says she'd be dead if it weren't for President Barack Obama's health care law....
- Coffee buzz: Study finds java drinkers live longer MILWAUKEE (AP) -- One of life's simple pleasures just got a little sweeter. After years of waffling research on coffee and health, even some fear that java might raise the risk of heart disease, a big study finds the opposite: Coffee drinkers are a little more likely to live longer. Regular or decaf doesn't matter....
- Antibiotic linked with rare but deadly heart risk CHICAGO (AP) -- An antibiotic widely used for bronchitis and other common infections seems to increase chances for sudden deadly heart problems, a rare but surprising risk found in a 14-year study....
- TB patient charged in Calif for not taking meds SAN FRANCISCO (AP) -- Armando Rodriguez was warned several times to continue taking his tuberculosis medicine....
- Study links vets to brain disease seen in athletes WASHINGTON (AP) -- A small study raises more concern about the long-term consequences of brain injuries suffered by thousands of soldiers - suggesting they may be at risk of developing the same degenerative brain disease as some retired football players....
- More doctors are ditching the old prescription pad WASHINGTON (AP) -- Dropping a paper prescription at the drugstore is becoming old-school: More than a third of the nation's prescriptions now are electronic, according to the latest count....
- Healthy eating can cost less, study finds WASHINGTON (AP) -- Is it really more expensive to eat healthy?...
NYTimes Health News
- Dr. Robert L. Spitzer, Noted Psychiatrist, Apologizes for... At the end of his career, Dr. Robert L. Spitzer has reached a painful conclusion: “I believe,” he wrote in a letter, “I owe the gay community an apology.”
- Trial Vaccine Made Some More Vulnerable to H.I.V., Study ... In 2007, a trial of an AIDS vaccine made by Merck was stopped early when it became clear that it was not protecting everyone. Now a follow-up study has confirmed the worst fears of researchers.
- A Stem-Cell-Based Drug Gets Approval in Canada Prochymal, developed by Osiris Therapeutics, is a preparation of mesenchymal stem cells, which are obtained from the bone marrow of healthy young adult donors.
- Rare Genetic Mutations May Underpin Diseases Because the mutations are so rare, costly studies involving large numbers of patients would be needed to identify their role in each disease.
- Well: Does Facebook Turn People Into Narcissists? Some research suggests that people who frequently update their Facebook status are more likely to exhibit narcissistic traits, but the social medium of choice for the self-absorbed may actually be Twitter.
- Well: Doctor and Patient: Increasing Organ Donor Enrollme... Showing people who were waiting to get a driver's license a short video about the impact of organ donation increased the number of organ donors by more than 10 percent, and the increase was especially dramatic among African-Americans.
- Well: Life, Interrupted: Hope Is My New Address I've left the isolation of the hospital after my bone marrow transplant and no longer need to be connected to IVs around the clock. I'm enjoying my freedom, but cancer continues to dictate my choices, writes Suleika Jaouad.
- HDL ‘Good Cholesterol’ Found Not to Cut Heart Risk People genetically prone to higher levels of HDL, often called “good cholesterol,” showed that they did not have any significant decrease in risk of cardiovascular disease.
- Popular Antibiotic May Raise Risk of Sudden Death Azithromycin may be risky for adults with heart problems, a new study finds, by possibly causing abnormal, potentially fatal, heart rhythms.
- Brain Disease Is Found in Veterans Exposed to Bombs The same degenerative brain disease found in football players and boxers has been found in veterans exposed to roadside bombs, a finding with potentially profound implications.
USAToday Health News
- Melanoma cases rising; young women at greatest risk Study says that could be because they are more likely to use tanning beds than men.
- Long use of any hormones raises women's breast cancer risk A new study tracked about 60,000 nurses and found that use of any kind of hormones for 10 years or more slightly raised the chances.
- Black women have trouble clearing cervical cancer virus Provocative new research might help explain why black women are so much more likely than whites to develop and die from cervical cancer.
- FDA rejects call to ban BPA from food packaging The FDA has rejected a petition from environmentalists that would have banned BPA from all food and drink packaging.
- Pool rules: Never drink the water, swim sick Utah residents know all about how to prevent one illness spread in pool, thanks to education campaigns started after a 2007 outbreak.
- Worried about lead poisoning in your home? What to do Should pre-1978 homes be tested even if no children live there? Are home-testing kits OK? Answers to your questions.
- CDC urges Boomers to get tested for hepatitis C U.S. health officials want all baby boomers to get tested for hepatitis C.
- French autistic kids mostly get psychotherapy In France, autistic children are more often sent to a psychiatrist where they get talk therapy.
- Georgia woman learns toll of flesh-eating bacteria A young woman fighting a flesh-eating bacteria has said "Let's do this" after being told that she will lose her hands and remaining foot.
- Black Madam to stand trial for illegal butt injections A judge ordered Padge Windslowe to stand trial on charges that include aggravated assault, and practicing medicine without a license.
msnbc.com:
- Study: Stay-at-home moms more sad, depressed A Gallup survey of 60,000 women released today found that stay-at-home moms are more likely to have felt depression, sadness, anger and worry than working mothers
- Consult doctor before stopping Zpak (Reuters) - U.S. health regulators said patients should not stop taking Pfizer Inc's Zithromax antibiotic without consulting a doctor, after a study showed a slightly higher rate of death among patients taking the drug compared to those on other antibiotics.
- More docts ditching the prescription pad Dropping a paper prescription at the drugstore is becoming old-school: More than a third of the nation's prescriptions now are electronic, according to the latest count.
- Drowning still a leading cause of death for toddlers A new CDC report finds that drowning remains the leading cause of death in children under age 4 other than birth defects.
- How to avoid weight gain? Eat on a schedule A new study of mice finds that when we eat may be an important factor in preventing weight gain.
- Laxative-free colon test may be as effective Colonoscopies could be made a bit more comfortable for people if they involved lying in a CT scanner, rather than being probed with an endoscope, and at the same time didn't require drinking upward of a gallon of laxative fluid beforehand — current requirements that most consider unpleasant.
- U.S. HIV aid has prevented 741,000 deaths: study NEW YORK (Reuters Health) - The United States foreign aid program that sends billions of dollars to African countries for HIV treatment and prevention has cut the number of people dying for any reason in those nations, a new study suggests.
- How often a week do you do it? Average is... "I have a very serious question for you," Kathie Lee asked Hoda. "Are you happy with your sex life?" She wasn't being nosy — it was purely for science purposes. A new survey from Yahoo! Shine and Fitness magazine asked women if they were as satisfied as they could be, in the bedroomal area.
- No, side bangs will not give you a lazy eye A story saying that side bangs -- like Nicole Richie's -- can give you a lazy eye is making the rounds on the Internet today. We truthsquad the claim.
- Sleepwalking more common than thought This, finally, may explain our cultural obsession with zombies: Long after dark, millions of Americans basically become one.
MSN Health News
- Diabetes Can Take a Toll on Your Emotions
- FDA Approves Generic Versions of Plavix
- Looking Away As You Get Needle Does Lower Pain, Study Shows
- Drowning Is Leading Cause of Kids' Accidental Death: CDC
- OSHA's Safety Tests Protect Workers at Little Cost: Study
- Parents Often Lose Sleep Over Child's Epilepsy, Study Finds
- It's Not Just What You Eat, It's When You Eat, Mouse Stud...
- Fewer Young Americans Smoking, Survey Finds
- Study Explores Distraction's Role in Pain Relief
- Early Study Hints at Link Between Certain Sunscreens, End...
CBS Health News
- "Gaydar" may be real, says Univ. of Washington study Subjects saw photographs of gay and straight men and women devoid of hair, makeup and ears, and predicted their sexual orientation at an above average percentage
- CDC urges hepatitis C test for all baby boomers born betw... From 1999 and 2007, there was a 50 percent increase in the number of Americans dying from hepatitis C-related diseases, CDC said
- FDA approves 7 companies to sell generic Plavix in pharma... Generics should be available in pharmacies immediately; Walmart and Sam's Club pharmacies nationwide will begin selling generic Plavix Saturday
- Diet during pregnancy is safe and reduces risk for compli... A calorie-restricted diet alone was more effective for weight loss than exercise or a combination of both, study showed
- Sugar may make you "stupid" but omega-3 might mitigate th... Rats given high-fructose corn syrup solution took longer to go through a maze than a group given omega-3 fatty acids as well
- Video: Sunglasses important for eye health Studies show that wearing sunglasses, even on cloudy days, will help prevent vision loss. Dr. Holly Phillips reports.
- Video: Reconsidering HDL as a "good" cholesterol A new study suggests that HDL, or "good" cholesterol, may not be protecting the heart. Instead, factors that increase HDL, such as exercise and not smoking, may be what's really helping. Dr. Jon LaPook reports.
- "Good" HDL cholesterol may not protect heart after all, s... Study of 170,000 adults found those with higher HDL levels due to genetics were no less likely to have a heart attack
- Video: Less email, less stress, says study A new study found that people who log off from their inbox are less stressed and more productive. Dr. Holly Phillips reports.
- New case of flesh-eating bacteria reported in S.C. mom Woman complained of leg cramps and saw what she thought was a blood clot on the back of her leg, which turned out to be necrotizing fasciitis
BBC UK Health News
- Dieting 'safe for pregnant women' Dieting in pregnancy is safe and does not carry risks for the baby, a review of research has suggested.
- Kids' cardiac service criticised An independent panel says cardiac services at Glasgow's Sick Children's Hospital "may be unsafe if critical staffing problems are not addressed".
- Father wants 'donation' lessons A father who lost his son to leukaemia is calling for schools and colleges to make a lesson on donating stem cells, blood and organs part of the curriculum.
- Parent classes 'not nanny state' Prime Minister David Cameron defends free parenting classes in England, denying they are the policy of a "nanny state".
- Statins 'benefit healthy people' Thousands of heart attacks and strokes could be prevented if the cholesterol-lowering drugs, statins, were more widely prescribed, research suggests.
- UK retains strict animal test law The UK says it will retain stricter animal testing standards than required by a new European Union Directive.
- Dementia patient 'had 106 carers' A woman claims her husband, who had dementia, was given 106 different carers in a single year.
- Oldest living kidney donor at 83 An 83-year-old man becomes the oldest person in the UK to donate a kidney while still alive, the NHS Blood and Transplant service says.
- Robotic arm controlled by thought Two patients who are paralysed from the neck down are able to control a robotic arm using their thoughts.
- Computer game for stroke patients Newcastle University helps to develop a computer game to help those who have suffered strokes.
Massachusetts Medical Society: New England Journal of Medicine: Table of Contents
- Lost in Translation — ¿Cómo se dice, “Patient Prote... New England Journal of Medicine, Volume 0, Issue 0, Ahead of Print.
- Emergency Departments, Medicaid Costs, and Access to Prim... New England Journal of Medicine, Volume 0, Issue 0, Ahead of Print.
- Regulatory Review of Novel Therapeutics — Comparison of... New England Journal of Medicine, Volume 0, Issue 0, Ahead of Print.
- Bisphosphonates for Osteoporosis — Where Do We Go from ... New England Journal of Medicine, Volume 0, Issue 0, Ahead of Print.
- Continuing Bisphosphonate Treatment for Osteoporosis — ... New England Journal of Medicine, Volume 0, Issue 0, Ahead of Print.
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- From an Ethics of Rationing to an Ethics of Waste Avoidance New England Journal of Medicine, Volume 0, Issue 0, Ahead of Print.
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- TODAY — A Stark Glimpse of Tomorrow New England Journal of Medicine, Volume 0, Issue 0, Ahead of Print.
NEJM This Week - Audio Summaries
- NEJM This Week - May 17, 2012 This summary covers the issue of May 17, 2012. Featured are articles on warfarin versus aspirin in heart failure, natalizumab and risk of progressive multifocal leukoencephalopathy, azithromycin and the risk of cardiovascular death, coffee drinking and mortality, STAT3 mutations in T-cell large granular lymphocytic leukemia, and stem cells and spinal cord repair; a review article on secondary prevention after ischemic stroke or transient ischemic attack; a case report of a woman with diplopia, headaches, and papilledema; and Perspective articles on the evolving primary care physician, on a comprehensive evaluation or checklist for mental illness, and on grief, depression, and the DSM-5.
- NEJM This Week - May 10, 2012 This summary covers the issue of May 10, 2012. Featured are articles on lenalidomide maintenance in multiple myeloma, PCI with or without on-site cardiac surgery, and reproductive technologies and the risk of birth defects; a review article on PCI without on-site cardiac surgery; a case report of a woman with fever and a generalized rash; and Perspective articles on the global challenge of HIV-HBV coinfection, on reassessing the benefits and risks of statins, and on measles in the 21st century.
- NEJM This Week - May 3, 2012 This summary covers the issue of May 3, 2012. Featured are articles on radioiodine ablation for thyroid cancer, transcatheter vs. surgical aortic-valve replacement, a registry of transcatheter aortic-valve implantation, and netting macrophages in the atherosclerotic plaque; a review article on two hundred years of surgery; a Clinical Problem-Solving article describing whistling in the dark; and Perspective articles on finding the right balance in patient care; on teaching the end-of-life conversation; on lecture halls without lectures; and on integrating clinical research with medical practice.
- NEJM This Week - April 26, 2012 This summary covers the issue of April 26, 2012. Featured are articles on medical therapy vs. bariatric surgery in diabetes, a genetic cause of familial diarrhea, low-dose CT in suspected appendicitis, and long-term effect of the Medicare Premier program on outcomes; a review article on insulin-pump therapy for type 1 diabetes mellitus; a case report of a man with paresthesias, jaundice, and anemia; and Perspective articles on making the best of hospital pay for performance, on controlling health care spending in Massachusetts, on financing graduate medical education, and on the Nightingale twins and transplantation science.
JAMA current issue
- A Lifecycle Approach to the Evaluation of FDA Approval Me...
- A 64-Year-Old Man With Motor Complications of Advanced Pa...
- A 52-Year-Old Man With Depression [Clinical Crossroads]
- Effect of a Multifaceted Intervention on Use of Evidence-... Context Studies have found that patients with acute coronary syndromes (ACS) often do not receive evidence-based therapies in community practice. This is particularly true in low- and middle-income countries.Objective To evaluate whether a multifaceted quality improvement (QI) intervention can improve the use of evidence-based therapies and reduce the incidence of major cardiovascular events among patients with ACS in a middle-income country.Design, Setting, and Participants The BRIDGE-ACS (Brazilian Intervention to Increase Evidence Usage in Acute Coronary Syndromes) trial, a cluster-randomized (concealed allocation) trial conducted among 34 clusters (public hospitals) in Brazil and enrolling a total of 1150 patients with ACS from March 15, 2011, through November 2, 2011, with follow-up through January 27, 2012.Intervention Multifaceted QI intervention including educational materials for clinicians, reminders, algorithms, and case manager training, vs routine practice (control).Main Outcome Measures Primary end point was the percentage of eligible patients who received all evidence-based therapies (aspirin, clopidogrel, anticoagulants, and statins) during the first 24 hours in patients without contraindications.Results Mean age of the patients enrolled was 62 (SD, 13) years; 68.6% were men, and 40% presented with ST-segment elevation myocardial infarction, 35.6% with non–ST-segment elevation myocardial infarction, and 23.6% with unstable angina. The randomized clusters included 79.5% teaching hospitals, all from major urban areas and 41.2% with 24-hour percutaneous coronary intervention capabilities. Among eligible patients (923/1150 [80.3%]), 67.9% in the intervention vs 49.5% in the control group received all eligible acute therapies (population average odds ratio [ORPA], 2.64 [95% CI, 1.28-5.45]). Similarly, among eligible patients (801/1150 [69.7%]), those in the intervention group were more likely to receive all eligible acute and discharge medications (50.9% vs 31.9%; ORPA,, 2.49 [95% CI, 1.08-5.74]). Overall composite adherence scores were higher in the intervention clusters (89% vs 81.4%; mean difference, 8.6% [95% CI, 2.2%-15.0%]). In-hospital cardiovascular event rates were 5.5% in the intervention group vs 7.0% in the control group (ORPA, 0.72 [95% CI, 0.36-1.43]); 30-day all-cause mortality was 7.0% vs 8.4% (ORPA, 0.79 [95% CI, 0.46-1.34]).Conclusion Among patients with ACS treated in Brazil, a multifaceted educational intervention resulted in significant improvement in the use of evidence-based therapies.Trial Registration clinicaltrials.gov Identifier: NCT00958958
- This Week in JAMA [This Week in JAMA]
- Improving Outcomes Following In-Hospital Cardiac Arrest: ...
- The Sad Truth About Early Initiation of Dialysis in Elder...
- New Genetic Discoveries and Treatment for Hepatitis C [Vi...
- Drowning in Plain Sight [A Piece of My Mind]
- Out-of-Hospital Administration of Intravenous Glucose-Ins... Context Laboratory studies suggest that in the setting of cardiac ischemia, immediate intravenous glucose-insulin-potassium (GIK) reduces ischemia-related arrhythmias and myocardial injury. Clinical trials have not consistently shown these benefits, possibly due to delayed administration. Objective To test out-of hospital emergency medical service (EMS) administration of GIK in the first hours of suspected acute coronary syndromes (ACS). Design, Setting, and Participants Randomized, placebo-controlled, double-blind effectiveness trial in 13 US cities (36 EMS agencies), from December 2006 through July 31, 2011, in which paramedics, aided by electrocardiograph (ECG)-based decision support, randomized 911 (871 enrolled) patients (mean age, 63.6 years; 71.0% men) with high probability of ACS. Intervention Intravenous GIK solution (n = 411) or identical-appearing 5% glucose placebo (n = 460) administered by paramedics in the out-of-hospital setting and continued for 12 hours. Main Outcome Measures The prespecified primary end point was progression of ACS to myocardial infarction (MI) within 24 hours, as assessed by biomarkers and ECG evidence. Prespecified secondary end points included survival at 30 days and a composite of prehospital or in-hospital cardiac arrest or in-hospital mortality, analyzed by intent-to-treat and by presentation with ST-segment elevation. Results There was no significant difference in the rate of progression to MI among patients who received GIK (n = 200; 48.7%) vs those who received placebo (n = 242; 52.6%) (odds ratio [OR], 0.88; 95% CI, 0.66-1.13; P = .28). Thirty-day mortality was 4.4% with GIK vs 6.1% with placebo (hazard ratio [HR], 0.72; 95% CI, 0.40-1.29; P = .27). The composite of cardiac arrest or in-hospital mortality occurred in 4.4% with GIK vs 8.7% with placebo (OR, 0.48; 95% CI, 0.27-0.85; P = .01). Among patients with ST-segment elevation (163 with GIK and 194 with placebo), progression to MI was 85.3% with GIK vs 88.7% with placebo (OR, 0.74; 95% CI, 0.40-1.38; P = .34); 30-day mortality was 4.9% with GIK vs 7.7% with placebo (HR, 0.63; 95% CI, 0.27-1.49; P = .29). The composite outcome of cardiac arrest or in-hospital mortality was 6.1% with GIK vs 14.4% with placebo (OR, 0.39; 95% CI, 0.18-0.82; P = .01). Serious adverse events occurred in 6.8% (n = 28) with GIK vs 8.9% (n = 41) with placebo (P = .26). Conclusions Among patients with suspected ACS, out-of-hospital administration of intravenous GIK, compared with glucose placebo, did not reduce progression to MI. Compared with placebo, GIK administration was not associated with improvement in 30-day survival but was associated with lower rates of the composite outcome of cardiac arrest or in-hospital mortality. Trial Registration clinicaltrials.gov Identifier: NCT00091507
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The Lancet
- [This Week in Medicine] May 19–25, 2012 An advisory committee of the US Food and Drug Administration (FDA) has recommended approval of combined tenofovir-emtricitabine for HIV-1 pre-exposure prophylaxis (PrEP) in high-risk populations, including for serodiscordant couples and men who have sex with men. A final decision from the FDA is expected on June 15.
- [Editorial] Chronic disease management in ageing populations The world's population is ageing owing to increasing life expectancy and declining fertility. The populations of low-income and middle-income countries are now joining those of high-income countries in facing an increasing burden of chronic diseases. A report, Shades of gray: a cross-country study of health and well-being of the old populations in SAGE countries, 2007—2011, jointly published on May 9 by the US Census Bureau and WHO, aims to improve documentation of health outcomes in such populations.
- [Comment] Genomics and world health: a decade on In May, 2002, under the auspices of its Advisory Committee on Health Research, WHO released Genomics and World Health, a report that assessed genomics research and its future possibilities. The report addressed issues of equitable sharing of benefits between low-income and high-income countries, ethical concerns, and integration into delivery of health services, and gave recommendations to ameliorate the problems identified. What progress has been made since release of the report?
- [Comment] Pazopanib and the treatment palette for soft-ti... Development of new therapeutics for adults with metastatic soft-tissue sarcoma has been frustratingly slow, with few effective drugs identified in the past 30 years. Despite their common mesenchymal origin, soft-tissue sarcomas are heterogeneous and increasing knowledge of their molecular biology will drive future drug development. Effective targeting of KIT mutations by imatinib for gastrointestinal stromal tumours has been a notable success story in modern sarcoma therapy. Unfortunately, similar successes for other soft-tissue sarcomas have been rare, since tumour growth is usually driven by complex molecular alterations.
- [Comment] Is minimally invasive preferable to open oesoph... In The Lancet, findings from Surya Biere and colleagues' multicentre randomised trial comparing minimally invasive oesophagectomy with open oesophagectomy provide evidence for short-term benefits of the minimally invasive technique for patients with resectable oesophageal cancer. Seven (12%) of 59 patients in the minimally invasive oesophagectomy group had pulmonary infection in hospital compared with 19 (34%) of 56 patients in the open oesophagectomy group (relative risk 0·35, 95% CI 0·16–0·78; p=0·005).
- [Comment] Extending the reach of BRAF-targeted cancer the... In The Lancet, Gerald Falchook and colleagues present results from a phase 1 trial of dabrafenib in patients with incurable solid tumours. In an expansion cohort, patients with BRAF-mutant tumours (including those with non-Val600Glu mutations) from three populations were treated at the recommended phase 2 dose: those with metastatic melanoma, those with non-melanoma solid tumours, and those with active melanoma brain metastases.
- [Comment] Tackling NCDs: a different approach is needed The NCD Alliance aims to put non-communicable diseases (NCDs) on the global agenda to address the NCD crisis. Improving outcomes in morbidity and mortality by 2015 will clearly depend to a large extent on tackling the burden of NCDs, especially in developing countries.
- [Editorial] A first for mental health in Canada Until May 8, Canada was the only member of the G8 without a national mental health strategy. However, the Mental Health Commission of Canada has remedied this shortcoming, releasing the first-ever national mental health strategy, entitled Changing Directions, Changing Lives.
- [Editorial] Drug regulation in India—the time is ripe f... To say that India's drug regulatory authority, the Central Drugs Standard Control Organisation (CDSCO)—whose remit includes new drug approval, licensing of manufacturing facilities, and regulation of drug trials—is not fit for purpose seems a gross understatement. A damning 118-page report from the Indian Parliamentary Standing Committee on Health and Family Welfare documents its successive failings. It describes a vast, geographically disseminated organisation that is dangerously understaffed: nine officers at headquarters deal with 20 000 applications, more than 200 meetings, 700 parliamentary questions, and 150 court cases per year.
- [Comment] Offline: Celebrating the Francis Crick Institut... Sitting over lunch with a scientist who serves on the governing body of a well-known UK research funder, together with the former Dean of a British medical school (and now one his university's senior administrators), the conversation turned to the Francis Crick Institute. The “Crick” is expected to become a jewel in the crown of global medical research. Initially founded by the Medical Research Council, Wellcome Trust, Cancer Research UK, and University College London (and more recently joined by Imperial College and King's College), the Francis Crick Institute says of itself that it “will play a key role in creating the foundation of knowledge on which this century's improvements in health will be based”.
Listen to The Lancet
- Listen to The Lancet: 11 May Discussion of the pioneering renal transplantation work of Dr Elmi Muller in South Africa.
- Listen to The Lancet: 04 May Ian Morgan discusses myopia, part of a three-part ophthalmology Series.
- Listen to The Lancet: 25 April Sabine Kleinert and Susan M Sawyer launch the latest Series on adolescent health.
- Listen to The Lancet: 18 April Musical excerpts from the World Doctors Orchestra, and highlights of the Physics and Medicine Series.
- Listen to The Lancet: 13 April Highlights from the April 14 issue, and introducing The Lancet News podcast.
- Listen to The Lancet: 07 April Anthony J Avery discusses a pharmacist-led, information technology intervention for medication errors.
- Listen to The Lancet: 30 March Discussion with Donna McKay, Physicians for Human Rights' new Executive Director.
- Listen to The Lancet: 23 March Andrew Chan assesses new research about aspirin and cancer prevention.
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Archives of Internal Medicine current issue
- Subclinical Hyperthyroidism and the Risk of Coronary Hear... Background Data from prospective cohort studies regarding the association between subclinical hyperthyroidism and cardiovascular outcomes are conflicting. We aimed to assess the risks of total and coronary heart disease (CHD) mortality, CHD events, and atrial fibrillation (AF) associated with endogenous subclinical hyperthyroidism among all available large prospective cohorts. Methods Individual data on 52 674 participants were pooled from 10 cohorts. Coronary heart disease events were analyzed in 22 437 participants from 6 cohorts with available data, and incident AF was analyzed in 8711 participants from 5 cohorts. Euthyroidism was defined as thyrotropin level between 0.45 and 4.49 mIU/L and endogenous subclinical hyperthyroidism as thyrotropin level lower than 0.45 mIU/L with normal free thyroxine levels, after excluding those receiving thyroid-altering medications. Results Of 52 674 participants, 2188 (4.2%) had subclinical hyperthyroidism. During follow-up, 8527 participants died (including 1896 from CHD), 3653 of 22 437 had CHD events, and 785 of 8711 developed AF. In age- and sex-adjusted analyses, subclinical hyperthyroidism was associated with increased total mortality (hazard ratio [HR], 1.24, 95% CI, 1.06-1.46), CHD mortality (HR, 1.29, 95% CI, 1.02-1.62), CHD events (HR, 1.21; 95% CI, 0.99-1.46), and AF (HR, 1.68; 95% CI, 1.16-2.43). Risks did not differ significantly by age, sex, or preexisting cardiovascular disease and were similar after further adjustment for cardiovascular risk factors, with attributable risk of 14.5% for total mortality to 41.5% for AF in those with subclinical hyperthyroidism. Risks for CHD mortality and AF (but not other outcomes) were higher for thyrotropin level lower than 0.10 compared with thyrotropin level between 0.10 and 0.44 mIU/L (for both, P value for trend, ≤.03). Conclusions Endogenous subclinical hyperthyroidism is associated with increased risks of total, CHD mortality, and incident AF, with highest risks of CHD mortality and AF when thyrotropin level is lower than 0.10 mIU/L.
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- Levothyroxine Treatment of Subclinical Hypothyroidism, Fa... Background Subclinical hypothyroidism (SCH) has been associated with ischemic heart disease (IHD); however, it is unknown whether treatment of SCH with levothyroxine sodium will reduce the risk of IHD. The aim of this study was to investigate the association between levothyroxine treatment of SCH with IHD morbidity and mortality. Methods We used the United Kingdom General Practitioner Research Database to identify individuals with new SCH (serum thyrotropin levels of 5.01-10.0 mIU/L and normal free thyroxine levels) recorded during 2001 with outcomes analyzed until March 2009. All analyses were performed separately for younger (40-70 years) and older (>70 years) individuals. Hazard ratios (HRs) for IHD events (fatal and nonfatal) were calculated after adjustment for conventional IHD risk factors, baseline serum thyrotropin levels, and initiation of levothyroxine treatment as a time-dependent covariate. Results Subclinical hypothyroidism was identified in 3093 younger and 1642 older individuals. For a median follow-up period of 7.6 years, 52.8% and 49.9% of younger and older patients with SCH were treated with levothyroxine, respectively. There were 68 incident IHD events in 1634 younger patients treated with levothyroxine (4.2%) vs 97 IHD events in 1459 untreated individuals (6.6%) (multivariate-adjusted HR, 0.61; 95% CI, 0.39-0.95). In contrast, in the older group there were 104 events in 819 treated patients (12.7%) vs 88 events in 823 untreated individuals (10.7%) (HR, 0.99; 95% CI, 0.59-1.33). Conclusions Treatment of SCH with levothyroxine was associated with fewer IHD events in younger individuals, but this was not evident in older people. An appropriately powered randomized controlled trial of levothyroxine in SCH examining vascular outcomes is now warranted.
- What Is the Clinical Importance of Subclinical Hyperthyro...
- What Does Off-label Prescribing Really Mean? [Editorial]
- Another Sobering Result for Home Telehealth--and Where We...
- Drug, Patient, and Physician Characteristics Associated W... Background Off-label prescribing may lead to adverse drug events. Little is known about its prevalence and determinants resulting from challenges in documenting treatment indication. Methods We used the Medical Office of the XXI Century electronic health record network in Quebec, Canada, where documentation of treatment indication is mandatory. One hundred thirteen primary care physicians wrote 253 347 electronic prescriptions for 50 823 patients from January 2005 through December 2009. Each drug indication was classified as on-label or off-label according to the Health Canada drug database. We identified off-label uses lacking strong scientific evidence. Alternating logistic regression was used to estimate the association between off-label use and drug, patient, and physician characteristics. Results The prevalence of off-label use was 11.0%; of the off-label prescriptions, 79.0% lacked strong scientific evidence. Off-label use was highest for central nervous system drugs (26.3%), including anticonvulsants (66.6%), antipsychotics (43.8%), and antidepressants (33.4%). Drugs with 3 or 4 approved indications were associated with less off-label use compared with drugs with 1 or 2 approved indications (6.7% vs 15.7%; adjusted odds ratio [AOR], 0.44; 95% CI, 0.41-0.48). Drugs approved after 1995 were prescribed off-label less often than were drugs approved before 1981 (8.0% vs 17.0%; AOR, 0.46; 95% CI, 0.42-0.50). Patients with a Charlson Comorbidity Index of 1 or higher had lower off-label use than did patients with an index of 0 (9.6% vs 11.7%; AOR, 0.94; 95% CI, 0.91-0.97). Physicians with evidence-based orientation were less likely to prescribe off-label (AOR, 0.93; 95% CI, 0.88-0.99), a 7% reduction per 5 points in the evidence section of the Evidence-Practicality-Conformity Scale. Conclusions Off-label prescribing is common and varies by drug, patient, and physician characteristics. Electronic prescribing should document treatment indication to monitor off-label use.
- A Randomized Controlled Trial of Telemonitoring in Older ... Background Efficiently caring for frail older adults will become an increasingly important part of health care reform; telemonitoring within homes may be an answer to improve outcomes. This study sought to assess differences in hospitalizations and emergency department (ED) visits among older adults using telemonitoring vs usual care. Methods A randomized controlled trial was performed among adults older than 60 years at high risk for rehospitalization. Participants were randomized to telemonitoring (with daily input) or to patient-driven usual care. Telemonitoring was accomplished by daily biometrics, symptom reporting, and videoconference. The primary outcome was a composite end point of hospitalizations and ED visits in the 12 months following enrollment. Secondary end points included hospitalizations, ED visits, and total hospital days. Intent-to-treat analysis was performed. Results Two hundred five participants were enrolled, with a mean age of 80.3 years. The primary outcome of hospitalizations and ED visits did not differ between the telemonitoring group (63.7%) and the usual care group (57.3%) (P = .35). No differences were observed in secondary end points, including hospitalizations, ED visits, and total hospital days. No significant group differences in hospitalizations and ED visits were found between the preenrollment period vs the postenrollment period. Mortality was higher in the telemonitoring group (14.7%) than in the usual care group (3.9%) (P = .008). Conclusions Among older patients, telemonitoring did not result in fewer hospitalizations or ED visits. Secondary outcomes demonstrated no significant differences between the telemonitoring group and the usual care group. The cause of greater mortality in the telemonitoring group is unknown. Trial Registration clinicaltrials.gov Identifier: NCT01056640
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Annals of Internal Medicine current issue
- A Comprehensive Care Management Program to Prevent Chroni... Background: Improving a patient's ability to self-monitor and manage changes in chronic obstructive pulmonary disease (COPD) symptoms may improve outcomes. Objective: To determine the efficacy of a comprehensive care management program (CCMP) in reducing the risk for COPD hospitalization. Design: A randomized, controlled trial comparing CCMP with guideline-based usual care. (ClinicalTrials.gov registration number: NCT00395083) Setting: 20 Veterans Affairs hospital-based outpatient clinics. Participants: Patients hospitalized for COPD in the past year. Intervention: The CCMP included COPD education during 4 individual sessions and 1 group session, an action plan for identification and treatment of exacerbations, and scheduled proactive telephone calls for case management. Patients in both the intervention and usual care groups received a COPD informational booklet; their primary care providers received a copy of COPD guidelines and were advised to manage their patients according to these guidelines. Patients were randomly assigned, stratifying by site based on random, permuted blocks of variable size. Measurements: The primary outcome was time to first COPD hospitalization. Staff blinded to study group performed telephone-based assessment of COPD exacerbations and hospitalizations, and all hospitalizations were blindly adjudicated. Secondary outcomes included non-COPD health care use, all-cause mortality, health-related quality of life, patient satisfaction, disease knowledge, and self-efficacy. Results: Of the eligible patients, 209 were randomly assigned to the intervention group and 217 to the usual care group. Citing serious safety concerns, the data monitoring committee terminated the intervention before the trial's planned completion after 426 (44%) of the planned total of 960 patients were enrolled. Mean follow-up was 250 days. When the study was stopped, the 1-year cumulative incidence of COPD-related hospitalization was 27% in the intervention group and 24% in the usual care group (hazard ratio, 1.13 [95% CI, 0.70 to 1.80]; P = 0.62). There were 28 deaths from all causes in the intervention group versus 10 in the usual care group (hazard ratio, 3.00 [CI, 1.46 to 6.17]; P = 0.003). Cause could be assigned in 27 (71%) deaths. Deaths due to COPD accounted for the largest difference: 10 in the intervention group versus 3 in the usual care group (hazard ratio, 3.60 [CI, 0.99 to 13.08]; P = 0.053). Limitations: Available data could not fully explain the excess mortality in the intervention group. Ability to assess the quality of the educational sessions provided by the case managers was limited. Conclusion: A CCMP in patients with severe COPD had not decreased COPD-related hospitalizations when the trial was stopped prematurely. The CCMP was associated with unanticipated excess mortality, results that differ markedly from similar previous trials. A data monitoring committee should be considered in the design of clinical trials involving behavioral interventions. Primary Funding Source: Veterans Affairs Cooperative Study Program.
- A Multidimensional Index and Staging System for Idiopathi... Background: Idiopathic pulmonary fibrosis (IPF) is a progressive fibrotic lung disease with an overall poor prognosis. A simple-to-use staging system for IPF may improve prognostication, help guide management, and facilitate research. Objective: To develop a multidimensional prognostic staging system for IPF by using commonly measured clinical and physiologic variables. Design: A clinical prediction model was developed and validated by using retrospective data from 3 large, geographically distinct cohorts. Setting: Interstitial lung disease referral centers in California, Minnesota, and Italy. Patients: 228 patients with IPF at the University of California, San Francisco (derivation cohort), and 330 patients at the Mayo Clinic and Morgagni-Pierantoni Hospital (validation cohort). Measurements: The primary outcome was mortality, treating transplantation as a competing risk. Model discrimination was assessed by the c-index, and calibration was assessed by comparing predicted and observed cumulative mortality at 1, 2, and 3 years. Results: Four variables were included in the final model: gender (G), age (A), and 2 lung physiology variables (P) (FVC and Dlco). A model using continuous predictors (GAP calculator) and a simple point-scoring system (GAP index) performed similarly in derivation (c-index of 70.8 and 69.3, respectively) and validation (c-index of 69.1 and 68.7, respectively). Three stages (stages I, II, and III) were identified based on the GAP index with 1-year mortality of 6%, 16%, and 39%, respectively. The GAP models performed similarly in pooled follow-up visits (c-index ≥71.9). Limitation: Patients were drawn from academic centers and analyzed retrospectively. Conclusion: The GAP models use commonly measured clinical and physiologic variables to predict mortality in patients with IPF. Primary Funding Source: University of California, San Francisco Clinical and Translational Science Institute.
- Diagnostic Accuracy of Laxative-Free Computed Tomographic... Background: Colon screening by optical colonoscopy (OC) or computed tomographic colonography (CTC) requires a laxative bowel preparation, which inhibits screening participation. Objective: To assess the performance of detecting adenomas 6 mm or larger and patient experience of laxative-free, computer-aided CTC. Design: Prospective test comparison of laxative-free CTC and OC. The CTC included electronic cleansing and computer-aided detection. Optical colonoscopy examinations were initially blinded to CTC results, which were subsequently revealed during colonoscope withdrawal; this method permitted reexamination to resolve discrepant findings. Unblinded OC served as a reference standard. (ClinicalTrials.gov registration number: NCT01200303) Setting: Multicenter ambulatory imaging and endoscopy centers. Participants: 605 adults aged 50 to 85 years at average to moderate risk for colon cancer. Measurements: Per-patient sensitivity and specificity of CTC and first-pass OC for detecting adenomas at thresholds of 10 mm or greater, 8 mm or greater, and 6 mm or greater; per-lesion sensitivity and survey data describing patient experience with preparations and examinations. Results: For adenomas 10 mm or larger, per-patient sensitivity of CTC was 0.91 (95% CI, 0.71 to 0.99) and specificity was 0.85 (CI, 0.82 to 0.88); sensitivity of OC was 0.95 (CI, 0.77 to 1.00) and specificity was 0.89 (CI, 0.86 to 0.91). Sensitivity of CTC was 0.70 (CI, 0.53 to 0.83) for adenomas 8 mm or larger and 0.59 (CI, 0.47 to 0.70) for those 6 mm or larger; sensitivity of OC for adenomas 8 mm or larger was 0.88 (CI, 0.73 to 0.96) and 0.76 (CI, 0.64 to 0.85) for those 6 mm or larger. The specificity of OC at the threshold of 8 mm or larger was 0.91 and at 6 mm or larger was 0.94. Specificity for OC was greater than that for CTC, which was 0.86 at the threshold of 8 mm or larger and 0.88 at 6 mm or larger (P = 0.02). Reported participant experience for comfort and difficulty of examination preparation was better with CTC than OC. Limitations: There were 3 CTC readers. The survey instrument was not independently validated. Conclusion: Computed tomographic colonography was accurate in detecting adenomas 10 mm or larger but less so for smaller lesions. Patient experience was better with laxative-free CTC. These results suggest a possible role for laxative-free CTC as an alternate screening method. Primary Funding Source: GE Healthcare and the American Cancer Society.
- Update in Pulmonary and Critical Care Medicine: Evidence ...
- Risk for Colorectal Cancer in Persons With a Family Histo... Background: The risk for colorectal cancer (CRC) is unclear for persons who have first-degree relatives with adenomatous polyps (adenomas). Purpose: To determine the validity of studies about this issue. Data Sources: MEDLINE and Cochrane databases from 1966 through 2011. Study Selection: Sequential review of titles, abstracts, and text from retrieved articles. Data Extraction: Study objective, study design, and numbers in study groups. Data Synthesis: Ten studies were identified that have been used to answer the question, "Does having a first-degree relative with an adenoma increase the risk for CRC?" We determined that they instead answer the question, "Does having a first-degree relative with CRC increase the risk for an adenoma?" We identified 2 additional studies that provide more relevant information. One study showed that the risk for CRC in persons who have first-degree relatives with adenomas is greater than the risk in persons who do not have first-degree relatives with adenomas (2.31% vs. 0.53%; relative risk, 4.36 [95% CI, 1.60 to 10.21]). The other study showed that the risk for CRC or large adenomas (≥1 cm) in persons who have first-degree relatives with large adenomas is greater than the risk in persons whose first-degree relatives do not have adenomas or CRC (8.3% vs. 4.2%; adjusted odds ratio, 2.27 [CI, 1.01 to 5.09]). Limitation: Even the 2 relevant studies have design problems that affect validity and generalizability. Conclusion: Most studies that are cited for the risk for CRC when relatives have adenomas do not address the issue. The 2 studies that do address the issue suggest an increased risk but have important methodological limitations. Properly designed studies are needed to measure the risk and identify the factors that modify it. Primary Funding Source: National Cancer Institute.
- Oral Direct Factor Xa Inhibitors Versus Low-Molecular-Wei... Background: Thromboembolic disease is the most frequent medical complication of arthroplasty. Purpose: To evaluate the benefits and harms of oral direct factor Xa inhibitors versus low-molecular-weight heparin (LMWH) in patients undergoing total hip or knee replacement. Data Sources: MEDLINE (1966 to December 2011), EMBASE (1980 to December 2011), and the Cochrane Central Register of Controlled Trials (up to December 2011), without language restrictions. References of reviews and abstracts of conferences were hand-searched. Study Selection: Randomized trials in patients undergoing hip or knee replacement that evaluated factor Xa inhibitors versus LMWH. Data Extraction: Two reviewers independently evaluated eligibility, abstracted the data, and assessed risk for bias. Data Synthesis: In 22 trials, high-quality evidence indicated that the absolute effect of factor Xa inhibitors and LMWH does not differ in terms of all-cause mortality (risk difference, 0 fewer deaths per 1000 patients [95% CI, 2 fewer to 1 more death]) or nonfatal pulmonary embolism (risk difference, 0 fewer events per 1000 patients [CI, 1 fewer to 2 more events]). Factor Xa inhibitors can prevent 4 instances of symptomatic deep venous thrombosis per 1000 treated patients (CI, 3 to 6 fewer events; high-quality evidence) but may increase major bleeding by 2 more events per 1000 patients (CI, 0 to 4 more events; moderate-quality evidence). High, but not lower, doses of oral factor Xa inhibitors increased bleeding compared with LMWH. Limitations: Most trials did not report outcome data for a substantial proportion of the patients. In 9 trials, the follow-up period was 14 days or less. Conclusion: Compared with LMWH, lower doses of oral factor Xa inhibitors can achieve a small absolute risk reduction in symptomatic deep venous thrombosis without increasing bleeding. Primary Funding Source: None.
- Prolonged Versus Standard-Duration Venous Thromboprophyla... Background: The optimal duration of thromboprophylaxis after major orthopedic surgery is unclear. Purpose: To compare the benefits and harms of prolonged versus standard-duration thromboprophylaxis after major orthopedic surgery in adults. Data Sources: Cochrane Central Register of Controlled Trials and Scopus from 1980 to July 2011 and MEDLINE from 1980 through November 2011, without language restrictions. Study Selection: Randomized trials reporting thromboembolic or bleeding outcomes that compared prolonged (≥21 days) with standard-duration (7 to 10 days) thromboprophylaxis. Data Abstraction: Two independent reviewers abstracted data and rated study quality and strength of evidence. Data Synthesis: Eight randomized, controlled trials (3 good-quality and 5 fair-quality) met the inclusion criteria. High-strength evidence showed that compared with standard-duration therapy, prolonged prophylaxis resulted in fewer cases of pulmonary embolism (PE) (5 trials; odds ratio [OR], 0.14 [95% CI, 0.04 to 0.47]; absolute risk reduction [ARR], 0.8%), asymptomatic deep venous thrombosis (DVT) (4 trials; relative risk [RR], 0.48 [CI, 0.31 to 0.75]; ARR, 5.8%), symptomatic DVT (4 trials; OR, 0.36 [CI, 0.16 to 0.81]; ARR, 1.5%), and proximal DVT (6 trials; RR, 0.29 [CI, 0.16 to 0.52]; ARR, 7.1%). Moderate-strength evidence showed fewer symptomatic objectively confirmed episodes of venous thromboembolism (4 trials; RR, 0.38 [CI, 0.19 to 0.77]; ARR, 5.7%), nonfatal PE (4 trials; OR, 0.13 [CI, 0.03 to 0.54]; ARR, 0.7%), and DVT (7 trials; RR, 0.37 [CI, 0.21 to 0.64]; ARR, 12.1%) with prolonged prophylaxis. High-strength evidence showed more minor bleeding events with prolonged prophylaxis (OR, 2.44 [CI, 1.41 to 4.20]; absolute risk increase, 6.3%), and insufficient evidence from 1 trial on hip fracture surgery suggested more surgical-site bleeding events (OR, 7.55 [CI, 1.51 to 37.64]) with prolonged prophylaxis. Limitations: Data relevant to knee replacement or hip fracture surgery were scant and insufficient. Most trials had few events; the strength of evidence ratings that were used may not adequately capture uncertainty in such situations. Conclusion: Prolonged prophylaxis decreases the risk for venous thromboembolism, PE, and DVT while increasing the risk for minor bleeding in patients undergoing total hip replacement. Primary Funding Source: Agency for Healthcare Research and Quality.
- How Variability in the Institutional Review Board Review ... Background: The Department of Health and Human Services recently called for public comment on human subjects research protections. Objective: To assess variability in reviews across institutional review boards (IRBs) for a multisite, minimal-risk trial of financial incentives for evidence-based hypertension care and to quantify the effect of review determinations on site participation, budget, and timeline. Design: A natural experiment occurring from multiple IRBs reviewing the same protocol for a multicenter trial (May 2005 to October 2007). Participants: 25 Veterans Affairs (VA) medical centers. Measurements: Number of submissions, time to approval, and costs were evaluated; patient complexity, academic affiliation, size, and location (urban or rural) between participating and nonparticipating VA medical centers were compared. Results: Of 25 eligible VA medical centers, 6 did not meet requirements for IRB review and 2 declined to participate. Of 17 applications, 14 were approved. The process required 115 submissions, lasted 27 months, and cost close to $170 000 in staff salaries. One IRB's concern about incentivizing a particular medication recommended by national guidelines prompted a change in our design to broaden our inclusion criteria beyond uncomplicated hypertension. The change required amending the protocol at 14 sites to preserve internal validity. The IRBs that approved the protocol classified it as minimal risk. The 12 sites that ultimately participated in the trial were more likely to be urban and academically affiliated and to care for more complex patients, which limits the external validity of the trial's findings. Limitation: Because data came from a single multisite trial in the VA system that uses a 2-stage review process, generalizability is limited. Conclusion: Complying with IRB requirements for a minimal-risk study required substantial resources and threatened the study's internal and external validity. The current review of regulatory requirements may address some of these problems. Primary Funding Source: Veterans Affairs Health Services Research and Development and the National Heart, Lung, and Blood Institute.
- Reactivation of Hepatitis B During Immunosuppressive Ther...
- Ethical Dilemmas and Malfunctions in Clinical Trials Rese...
Annals of Internal Medicine Podcast
- Issue Summary for May 15, 2012 Summary of the May 15, 2012 issue, including articles on a case management program to prevent COPD hospitalizations, predicting survival in idiopathic pulmonary fibrosis, laxative-free computed tomographic colonography, risk for colorectal cancer, strategies and duration of thromboprophylaxis after major orthopedic surgery, Institutional Review Boards, an Update in pulmonary and critical care medicine, and reactivation of hepatitis B virus infection during immunosuppressive therapy.
- Issue Summary for May 1, 2012 Summary of the May 1, 2012 issue, including articles on breast cancer screening, hospital strategies for reducing mortality rates in acute myocardial infarction, vitamin D deficiency and risk for clinical disease outcomes, an Update in general internal medicine, and a pair of In the Balance commentaries on geriatric training.
- Issue Summary for April 17, 2012 Summary of the April 17, 2012 issue, including articles on preexposure chemoprophylaxis for HIV infection, epidural injections for lumbosacral radiculopathy, new fibrate use and acute renal outcomes, chronic kidney disease, prostate cancer, and a commentary on gift versus consent models for human biological samples.
- Issue Summary for April 3, 2012 Summary of the April 3, 2012 issue, including articles on health care-associated HCV infection, an intervention to increase organ donation, mammography screening, rapid influenza diagnostic tests and antiviral therapy for influenza, guideline development methods, and use of Medicare data to assess physician performance.
- Issue Summary for March 20, 2012 Summary of the March 20, 2012 issue including articles about diabetes treatment, vitamin D supplementation, cardiac risk assessment, antiplatelet therapy in patients with chronic kidney disease, and H1N1 influenza research.
- Issue Summary for March 6, 2012 Summary of the March 6, 2012 issue including articles on rheumatoid arthritis treatment, physician understanding of evidence on screening tests, non-steroidal anti-inflammatory drugs and inflammatory bowel disease, surrogate decision-making, comparative effectiveness research on colorectal cancer screening, and urinary tract infection. Also highlights early release articles on avian influenza research, chronic kidney disease, influenza diagnosis and treatment, and HIV guidelines.
- Issue Summary February 21, 2012 Summary of the February 21 2012 issue including articles on family history in cardiovascular risk assessment, vial hepatitis, fructose and body weight, Continuing Medical education, and HIV prevention.
- Issue Summary for February 7, 2012 Summary of the February 7, 2012 issue featuring information on influenza transmission, implantable cardioverter defibrillators, ovarian cancer screening, palliative care, immunization, and drug therapy for type 2 diabetes.
- Issue Summary for January 17, 2012 Summary of the January 17 2012 issue featuring information on HIV prevention, vitamin D supplementation, sleep apnea, autopsy, physical disability, and high value care.
- Issue Summary for January 3, 2012 Summary of the January 3, 2012 featuring information on neck pain, biosurveillance, hospital mortality measures, type 2 diabetes guidelines, dementia, and plantar fasciitis. An issue supplement contains the 6th edition of the ACP Ethics Manual.
Journal of Hospital Medicine
- Training a hospitalist workforce to address the intensivi...
- Impact of in-hospital enteroviral polymerase chain reacti... BACKGROUND:Enteroviral meningitis is a common cause of meningitis in children which requires only supportive care.OBJECTIVE:To evaluate the impact of implementing an in-hospital enteroviral polymerase chain reaction (EVPCR) testing protocol on the clinical management of children with meningitis.DESIGN:Retrospective cohort study.POPULATION:Children <19 years old with meningitis.INTERVENTION:EVPCR testing differed by time period: send-out testing protocol from July 1, 2006–June 23, 2008 (pre-period) versus in-house testing protocol from June 24, 2008–June 30, 2010 (post-period).MEASUREMENTS:Test turnaround time, test utilization, length of stay, and duration of parenteral antibiotics.RESULTS:Of the 441 study patients, 216 (49%) presented during the post-period. Median age was 2.9 months (interquartile range, 1.5–96 months). Test turnaround time decreased with the in-house test (53 hours pre vs 13 hours post, P < 0.001), and test utilization increased (28% pre vs 62% post, P < 0.001). Among children with a positive EVPCR test, both length of stay (44 hours pre vs 28 hours post, P = 0.005) and duration of parenteral antibiotics (48 hours pre vs 36 hours post, P = 0.04) decreased in the post-period. No change in either of these outcomes was observed in children with meningitis and a negative EVPCR test.CONCLUSION:In-house EVPCR testing reduced test turnaround time, increased test utilization, and reduced both length of stay and duration of parenteral antibiotics for children with a positive result. Clinicians caring for children with meningitis should have access to in-hospital EVPCR testing. Journal of Hospital Medicine 2012; © 2012 Society of Hospital Medicine
- Participation in unprofessional behaviors among hospitali... BACKGROUND:Unprofessional behaviors undermine the hospital learning environment and quality of patient care.OBJECTIVE:To quantify perceptions of, and participation in, unprofessional behaviors among hospitalists.DESIGN:Observational survey study.SETTING:Three academic health centers.SUBJECTS:Hospitalists.MEASUREMENTS:Observation, participation in, and perceptions of unprofessional behaviors.RESULTS:Response rate was 76% (77/101). Nearly all behaviors were perceived as unprofessional (“unprofessional” or “somewhat unprofessional” on the Likert scale). Participation in egregious behaviors (ie, falsifying records) was low (<5%). The most frequent behaviors reported were having personal conversations in patient corridors (67.1%), ordering a test as “urgent” to expedite care (62.3%), and making fun of other physicians (40.3%). Four factors accounted for 76% of survey variance: (1) making fun of others; (2) learning environment (eg, texting during conferences); (3) workload management (eg, celebrating a blocked-admission); and (4) time pressure (eg, signing out work early). Hospitalists with less clinical time (<50% full-time equivalents [FTE]) were more likely to report making fun of others (β = 0.94 [95% CI 0.32–1.56], P = 0.004). Younger hospitalists (β = 0.87 [95% CI 0.07–1.67], P = 0.034) and those with administrative time (β = 0.61 [95% CI 0.11–1.10], P = 0.017) were more likely to report participating in workload management behaviors. Hospitalists who work night shifts were more likely to report participating in time-pressure behaviors (β = 0.67 [95% CI 0.17–1.17], P = 0.010). Workload management and learning environment varied by site.CONCLUSION:While hospitalist participation in unprofessional behaviors is low, job characteristics (clinical, administrative, nights), age, and site were associated with different types of unprofessional behavior that may affect the learning environment and patient care. Journal of Hospital Medicine 2012;. © 2012 Society of Hospital Medicine
- Observations during development of an internal medicine r... BACKGROUND:Despite the future potential of using ultrasound stethoscopes to augment the bedside cardiac physical, few data exist on a general cardiovascular imaging protocol that can be taught to physicians on a perpetual basis as a curriculum in graduate medical education.METHODS:During the past decade, we developed and integrated a cardiovascular limited ultrasound training program within the confines of an internal medicine residency. The evidence-based rationale for the exam, the teaching methods, and curriculum are delineated, and subsequent observations regarding program requirements, proficiency, and academic outcomes are explored. Analysis of variance and linear regression assessed for relationships between academic scores, chief resident selection, and gender to proficiency in ultrasound.RESULTS:A brief, 5-minute cardiovascular limited ultrasound exam (CLUE) was taught using both didactic and bedside methods, and practiced primarily within the cardiology consult, outpatient clinic, and intensive care rotations. Program costs were minimized by employing readily available institutional resources. After a 2-year lead-in training phase, the subsequent 4 years of senior resident performance (n = 41 residents) showed an 81% pass rate in CLUE competency. Resident ultrasound performance did not relate to academic scores (r = 0.05, P = 0.75), chief resident selection, nor gender. Observations regarding resident pitfalls in CLUE practice and increased participation in extracurricular research are described.CONCLUSIONS:We report our initial experience in developing and implementing a training program for bedside cardiovascular ultrasound examination that employed evidence-based techniques, set proficiency goals, and assessed resident performance. It may be feasible to teach future internist–hospitalists the technique of bedside ultrasound during residency. Journal of Hospital Medicine 2012;. © 2012 Society of Hospital Medicine
- Adverse outcomes associated with gastroesophageal reflux ... OBJECTIVE:To evaluate for adverse outcomes associated with gastroesophageal reflux disease (GERD) following an apparent life-threatening event (ALTE) and potential risk factors of these outcomes.STUDY DESIGN:Retrospective cohort study of well-appearing infants (<12 months) admitted for ALTE. Patients were followed for adverse outcomes associated with GERD (including aspiration pneumonia, failure-to-thrive, or anti-reflux surgery), second ALTE, or death. Risk factors evaluated included: age, prematurity, gender, previous event, diagnosis of GERD, gastrointestinal (GI) testing positive for gastroesophageal reflux, length of stay (LOS), and neurologic impairment diagnosed in follow-up.RESULTS:Four hundred sixty-nine patients met inclusion criteria, mean age was 45 days, 110 (22%) were premature. Patients were followed for an average of 7.8 years; 3.8% of all patients had an adverse outcome associated with GERD. The only significant risk factors were a longer LOS, and development of neurological impairment. A diagnosis of GERD and positive reflux testing during the initial hospitalization were not associated with adverse outcomes associated with GERD.CONCLUSIONS:Adverse outcomes associated with GERD are rare following an ALTE. Patients who developed neurological impairment and a longer initial LOS were at higher risk for developing these outcomes. Positive testing for gastroesophageal reflux during hospitalization for ALTE did not predict adverse outcomes associated with GERD. Journal of Hospital Medicine 2012;. © 2012 Society of Hospital Medicine
- The hand that feeds you
- Predictors of medication adherence postdischarge: The imp... BACKGROUND:Optimizing postdischarge medication adherence is a target for avoiding adverse events. Nevertheless, few studies have focused on predictors of postdischarge medication adherence.METHODS:The Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study used counseling and follow-up to improve postdischarge medication safety. In this secondary data analysis, we analyzed predictors of self-reported medication adherence after discharge. Based on an interview at 30-days postdischarge, an adherence score was calculated as the mean adherence in the previous week of all regularly scheduled medications. Multivariable linear regression was used to determine the independent predictors of postdischarge adherence.RESULTS:The mean age of the 646 included patients was 61.2 years, and they were prescribed an average of 8 daily medications. The mean postdischarge adherence score was 95% (standard deviation [SD] = 10.2%). For every 10-year increase in age, there was a 1% absolute increase in postdischarge adherence (95% confidence interval [CI] 0.4% to 2.0%). Compared to patients with private insurance, patients with Medicaid were 4.5% less adherent (95% CI −7.6% to −1.4%). For every 1-point increase in baseline medication adherence score, as measured by the 4-item Morisky score, there was a 1.6% absolute increase in postdischarge medication adherence (95% CI 0.8% to 2.4%). Surprisingly, health literacy was not an independent predictor of postdischarge adherence.CONCLUSIONS:In patients hospitalized for cardiovascular disease, predictors of lower medication adherence postdischarge included younger age, Medicaid insurance, and baseline nonadherence. These factors can help predict patients who may benefit from further interventions. Journal of Hospital Medicine 2012;. © 2012 Society of Hospital Medicine
- Comparative effectiveness of low-molecular-weight heparin... BACKGROUND:Both unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) are approved for venous thromboembolism (VTE) prophylaxis. Which agent is superior remains controversial.OBJECTIVE:To compare the effectiveness, complications, and costs of UFH and LMWH as VTE prophylaxis for hospitalized medical patients.DESIGN:Retrospective cohort.SETTING:Three hundred thirty-three acute care facilities in 2004–2005.PATIENTS:Adults with 4 common medical diagnoses considered to carry moderate-to-high risk of VTE. Excluded were patients on warfarin or with hospital stays of ≤2 days. VTE prophylaxis was assessed from billing data.INTERVENTION:None.MEASUREMENTS:VTE, major bleeding or heparin-induced thrombocytopenia, mortality, and cost.RESULTS:Of 32,104 patients who received prophylaxis, 55% received LMWH and the remainder received UFH. The hospital where the patient obtained care was the strongest predictor of receiving LMWH. VTE was observed in 163 (0.51%) patients; complications, followed by stopping therapy, were rare (<0.2%). In analysis adjusted for the propensity for UFH and other covariates, patients treated with UFH had an odds ratio for VTE of 1.04 (95% confidence interval [CI] 0.76 to 1.43) compared to LMWH. In a grouped treatment model, the odds of VTE with UFH was 1.14 (95% CI 0.72 to 1.81). Adjusted odds of bleeding with UFH compared to LMWH were 1.64 (95% CI 0.50 to 5.33), adjusted odds of complications followed by stopping prophylaxis were 2.84 (95% CI 1.43 to 45.66), and adjusted cost ratio was 0.97 (95% CI 0.90 to 1.05).CONCLUSIONS:For VTE prophylaxis, the effectiveness and cost of LMWH and UFH are similar, but LMWH is associated with fewer complications. Journal of Hospital Medicine 2012;. © 2012 Society of Hospital Medicine
- Impact of hyponatremia and the syndrome of inappropriate ... BACKGROUND:Hyponatremia is associated with pneumonia, and aspiration pneumonia is common in the elderly, however, there has been no study of hyponatremia in this population.OBJECTIVE:To determine the impact of hyponatremia on mortality in elderly patients with aspiration pneumonia, while focusing on the comparison between those with and without the syndrome of inappropriate antidiuresis (SIAD).DESIGN:Retrospective review of existing database and medical records.SETTING:A community teaching hospital in Japan.PATIENTS:Two hundred and twenty-one elderly patients hospitalized with aspiration pneumonia.MEASUREMENTS:Multivariate logistical regression models were used to compare 30-day and in-hospital mortality, in patients with hyponatremia of various severities and etiologies, with that in patients with normal serum sodium concentrations.RESULTS:Sixty-five (29%) of 221 patients had hyponatremia. Of these 62 (95%) had hypotonic hyponatremia, which were further assessed as having hypovolemic (39 [63%]), hypervolemic (3 [5%]), and euvolemic (20 [32%]) hyponatremia. Of the 20 euvolemic patients, 14 (70%) had SIAD. Both moderate and severe hypotonic hyponatremia were significantly associated with increased in-hospital mortality (odds ratio [OR] 6.05, 95% confidence interval [CI] 1.46–25.0, and OR 5.65, 95% CI 1.14–28.1, respectively). Hyponatremia due to SIAD was significantly associated with both increased 30-day mortality (OR 7.40, 95% CI 1.73–31.7) and increased in-hospital mortality (OR 22.3, 95% CI 4.26–117). In contrast, hypovolemic hyponatremia was not significantly associated with increased mortality.CONCLUSIONS:Hyponatremia due to SIAD was strongly associated with increased mortality in elderly patients with aspiration pneumonia, whereas hypovolemic hyponatremia was not associated with increased mortality. Journal of Hospital Medicine 2012;. © 2012 Society of Hospital Medicine
- “Can we just stop and talk?” patients value verbal co... BACKGROUND:Studies show that hospitalized patients often do not understand their postdischarge care plan. There are few studies about patients' preferences regarding the content of discharge care plans.OBJECTIVE:To identify what patients view as essential elements of a post-hospitalization plan.DESIGN:Anonymous written survey distributed on the second day of admission to internal medicine wards.SETTING:An academic tertiary care hospital and an academic county hospital in Seattle, Washington.PATIENTS:Two hundred English-speaking adult inpatients ≥18 years or their proxies.RESULTS:The majority of patients (64.5%) surveyed wanted verbal discharge instructions, with only 10.5% requesting written instructions (P < 0.0001). One hundred percent of patients valued the following discharge instructions as essential: “when you need to follow-up with [primary care provider] PCP,” “warning signs to call PCP,” and “medicines to continue post-hospitalization.” One hundred percent of patients wanted “a lot of information about my condition” and “test results,” but only 39% wanted “a lot of information about my medications” (P < 0.0001). When asked to choose the most important piece of discharge instruction related to their disease, 67.5% of patients chose “lifestyle changes.” One hundred percent of patients thought that personal communication between the inpatient provider and the outpatient primary care provider was “extremely important” or “essential.”CONCLUSION:Patients uniformly placed high value on: 1) verbal communication about discharge care plans; 2) information about lifestyle changes for improved health; and 3) personal communication between inpatient and outpatient providers. Journal of Hospital Medicine 2012. © 2012 Society of Hospital Medicine
Evidence-Based Medicine current issue
- Purpose and procedure The general purpose of Evidence-Based Medicine is to select from the health-related literature* those articles reporting important advances in internal medicine, general and family practice, surgery, psychiatry, paediatrics, and obstetrics and gynaecology, and whose results are most likely to be both true and useful. These articles are described, critiqued and commented on by clinical experts. The specific purposes of Evidence-Based Medicine are: to identify, using predefined criteria, the best original and review articles on the cause, course, diagnosis, prevention, treatment, quality of care, or economics of disorders in the foregoing fields to provide a description and expert commentary on the context of each article, its methods, and the clinical applications that its findings warrant to disseminate the summaries in a timely fashion The BMJ Publishing Group publishes Evidence-Based Medicine. Criteria for selection and review of articles All articles in a...
- Hydroxycarbamide for very young children with sickle cell... Context Sickle cell anaemia (SCA) is a disorder of haemoglobin polymerisation that results in vaso-occlusion and haemolytic anaemia, culminating in organ injury and early mortality. Elevated fetal haemoglobin has been associated with a less severe phenotype leading to an interest in hydroxycarbamide (also known as hydroxyurea) use. The MSH study1 demonstrated that hydroxycarbamide in adults with severe sickle cell disease reduced painful events, hospitalisations, acute chest syndrome and the number of blood transfusions. The HUG–KIDS study,2 a phase I/II study, demonstrated safety and haematologic responses to hydroxycarbamide therapy in children 5–15 years of age. The HUSOFT study3 was conducted in infants and very young children for 2 years with similar end points and favourable results. Two adult trials document the benefits of hydroxycarbamide in reducing mortality in SCA.4 5 The BABY HUG study was designed to answer whether...
- Randomised trial of radical prostatectomy versus watchful... Context Data comparing surgery versus watchful waiting for prostate cancer are important, and the results are also relevant when evaluating whether and when screening for prostate cancer is effective.1 Thus, deciding whether such study results are valid, and how well they generalise, is a prominent challenge in men's health. Methods This randomised trial seeks to determine whether mortality from prostate cancer is lower after radical prostatectomy than with primary expectant management. As an ongoing project for more than 20 years, prior major reports appeared in 2002,2 20053 and 2008.4 The current report extends follow-up by 3 years and focuses on low-risk prostate cancer (Gleason histological score <7, prostate-specific antigen level <10 ng/ml) and younger men (<65 years of age). Findings In summary, 695 men with localised and well-differentiated or moderately differentiated prostate cancer (mean age 65...
- Systematic review of observational studies finds increase... Context Proton pump inhibitors (PPIs) were initially considered to be potentially beneficial for bone as they were perceived to be able to inhibit acidic degradation by osteoclasts and thus have antiresorptive potential.1 However, this has been shown not to be the case, as the original studies were based on compounds differing from those used clinically.1 Studies of bone density have failed to show any major changes in bone density with PPIs.2 Short-term studies have failed to show an effect on calcium absorption by PPIs.3 The present study examines whether a relationship exists between the use of PPIs and histamine-2-receptor antagonists (H2RAs) and adverse effects on the skeleton. The question raised is important from an epidemiological point of view as antacid drugs are widely prescribed and available over-the-counter in some locales. Methods Yu and colleagues applied standard meta-analytic techniques...
- Oxygen may reduce dyspnoea in people with COPD who have m... Context Although supplemental oxygen (SupplO2) has been shown to prolong survival in chronic obstructive pulmonary disease (COPD) patients with severe hypoxaemia (ie, PaO2<55 mm Hg or PaO2 55–59 mm Hg with cor pulmonale or polycythaemia), benefits in non-hypoxaemic COPD patients are less clear. Prescribing SupplO2 for such patients is highly variable, and it is common and very costly. As such, there is a strong rationale to clarify the indications.1 This meta-analysis evaluates the evidence regarding the benefits of SupplO2 to relieve dyspnoea and enhance exercise performance and quality of life (QOL) in COPD patients whose baseline resting oxygenation is not substantially impaired. Methods The article follows the standard Cochrane review approach, that is, considers all (and only) randomised controlled trials, irrespective of blinding (ie, of inhaling oxygen vs medical air) in this case; specifies the intervention (ie, oxygen or medical air as administered through...
- The administration of corticosteroids to 34-36-week pregn... Context A single course of antenatal corticosteroids (ACS) is an unusual example of an intervention which leads to a cost savings and an improved health outcome for infants born before 34-week gestational age (GA).1 However, the evidence with regards to its effectiveness in late preterm infants (those born between 34 and before 36 6/7 weeks) is unknown. Methods A single-centre, double-blind, randomised controlled trial of a single course of antenatal corticosteroids versus placebo in women at high risk of preterm birth between 34 and 36 6/7 weeks GA. Between April 2008 and June 2010, 320 women were randomised, 163 to ACS and 157 to placebo, at a large tertiary hospital in Recife, Brazil. Women randomised to the ACS group received two doses of 12 mg of β-methasone intramuscularly every 24 h, and those randomised to placebo received a placebo of similar appearance. Women were...
- Cardiac resynchronisation therapy reduces mortality in pa... Context Cardiac resynchronisation therapy (CRT) is now a well-established therapy for certain subgroups of patients with heart failure, with a large body of evidence demonstrating improvement in symptoms and beneficial changes in cardiac structure and function. American and European guidelines support its use in patients with New York Heart Association (NYHA) class III and IV heart failure, prolonged QRS duration and left ventricular ejection fraction <35%. The COMPANION trial1 demonstrated an all-cause mortality benefit of CRT when combined with implantable cardioverter defibrillator (ICD) therapy in this subgroup, and, subsequently, the CARE-HF trial2 established a mortality benefit attributable to CRT alone when compared with optimal medical therapy (OMT). More recently, the REVERSE3 and MADIT-CRT4 trials in patients with less severe, NYHA class I and II heart failure symptoms showed improved cardiac function and reduction in heart failure hospitalisation in patients treated...
- In two parallel pragmatic equivalence trials, leukotriene... Context Asthma is a common condition for which there are robust evidence-based guidelines.1 Such guidelines are by definition based on the gold standard of randomised controlled trials (RCTs) which often have restrictive, inclusion and exclusion criteria, such that patients enrolled are not representative of patients seen in real world settings. Pragmatic trial designs have been suggested as a method of overcoming some of these limitations.2 Methods In two parallel, multicentre open-labelled pragmatic trials, Price and colleagues evaluated the effectiveness of inhaled corticosteroids (ICS) versus leukotriene receptor antagonists (LTRAs) as initial asthma therapy (in trial 1) and the addition of an LTRA or a long-acting β agonist (LABA), by random allocation, for participants who remained uncontrolled after 12 weeks of ICS (in trail 2). Participants with physician-diagnosed asthma were recruited from 53 primary care practices in the UK. The study was not funded...
- Early (at 34-35 weeks) external cephalic version reduced ... Commentary on: Hutton EK, Hannah ME, Ross SJ, et al.. The Early External Cephalic Version (ECV) 2 Trial: an international multicentre randomised controlled trial of timing of ECV for breech pregnancies. BJOG 2011;118:564–77.
- Warming local anaesthetic prior to injection reduces inje... Context For many patients, the worst part of a procedure, such as a tooth extraction or a carpal tunnel decompression, is likely to be the initial pain following the insertion of a needle and the injection of local anaesthetic. There are reports that warming local anaesthetics before injection can reduce pain, but the effectiveness of this approach has not been accurately determined. The purpose of this systematic review was to examine whether the strategy of warming local anaesthetic prior to injection reduces self-report of pain. Methods The authors used an accepted search strategy and analysis of randomised or pseudo-randomised studies that compared warmed local anaesthetics with those not warmed before injection. Some of the studies involved volunteers while others involved subjects receiving injections for different indications such as surgery in the head and neck region, closure of lacerations, venipuncture, carpal tunnel decompression or dental anaesthesia in...
Cleveland Clinic Journal of Medicine current issue
- Lung cancer screening: One step forward
- Hyperpigmentation and hypotension
- Correction
- Disparities in prostate cancer in African American men: W... African American men have a higher incidence of prostate cancer than white men, and also a higher rate of death due to prostate cancer. Although both biologic and socioeconomic factors may be to blame, better screening in this population may help to close the gap.
- Personalizing patient care
- Family history: Still relevant in the genomics era Even at the dawn of the genomics era, the family history is still very relevant, being a proxy for genetic, environmental, and behavioral risks to health. The family history can be used to inform risk stratification, allowing for judicious use of screening and opening the door to early and even prophylactic treatment. This review aims to re-energize our use of the family history in primary care practice.
- The rationale for, and design of, a lung cancer screening... We are entering a new era in which lung cancer screening may be considered the standard of care. The National Lung Screening Trial (NLST) has shown that the number of deaths due to lung cancer can be reduced through screening with low-dose computed tomography (CT) in a high-risk population (N Engl J Med 2011; 365:395–409). Key issues—such as how to manage lung nodules, how to improve cost-effectiveness, and how to minimize radiation exposure—need to be addressed when designing a lung cancer screening program. Time and further technical advances will help to optimize the programs that are developed.
- Lung cancer screening: What to expect
- Geriatrics update 2012: What parts of our practice to cha... Many new guidelines and studies of interest to the geriatric population have emerged in the areas of falls and fracture prevention, cardiovascular care, depression, and Alzheimer disease. Some of these guidelines and studies translate to immediate changes that should be made to clinical practice; others are new areas of controversy.
- Painful red hands and feet
QJM - current issue
- Elements: in this month's issue
- Cytomegalovirus: recent progress in understanding pathoge... Cytomegalovirus continues to be an important pathogen in a variety of patient groups especially the neonate and the transplant recipient, and has implicated in a range of pathologies including inflammatory disease and in contributing to early death in ageing populations. This review will focus on advances in understanding the virus–host interaction and options for the new therapeutic control measures.
- Recent advances in management of gout Incidence and prevalence of gout have markedly increased over the last few decades in keeping with the rise in prevalence of obesity and metabolic syndrome. Until recently, management of gout in patients with associated metabolic syndrome and comorbid illnesses such as renal impairment was difficult because of limited treatment options. However, significant progress has been made in the last few years, with introduction of new treatments such as interleukin-1 antagonists for management of acute gout, and febuxostat and pegloticase for chronic gout. The association of gout with alcohol, dietary purines and fructose ingestion has been confirmed in large prospective studies, thus enabling the clinician to now provide evidence-based advice to patients. Recent efficacy and safety data favour lower over higher doses of colchicine, and oral corticosteroids over non-steroidal anti-inflammatory drugs for patients with acute gout. Local ice therapy might help to differentiate gout from other forms of inflammatory arthritis, and supplementation with vitamin C help to reduce risk of gout. Several other drugs with rational mechanisms of action are in the pipeline, and likely to be introduced over the next few years. A new era has thus begun in the field of gout.
- Serum 'free' copper in Wilson disease Background: The relationship between serum ‘free’ copper and urine copper in patients with Wilson disease has not been explored. Aim: The object of this study is to ascertain if there is a direct relationship between these two parameters. Method: The case notes of 320 patients with Wilson disease, seen between 1960 and 1987, have been reviewed. Eighty of these patients had received no treatment before referral and the results of serum ‘free’ copper and urine copper on admission and at one year of treatment have been analysed. Results: Except for patients with acute haemolysis, the ratio between ‘free’ serum copper and urine copper before treatment, on average, is around 7:1, after treatment this falls to around 5:1. But results show a wide scatter and there is no direct linear relationship. Conclusion: The term ‘free’ copper is misleading and should be replaced by the more cumbersome but accurate term ‘noncaeruloplasmin bound copper’. Most ‘free’ copper is complexed to albumin and is only available for excretion if there is significant protein loss by the kidneys.
- Prevalence and markers of advanced liver disease in type ... Background: Type 2 diabetes is a risk factor for progression of non-alcoholic fatty liver disease (NAFLD) to fibrosis and cirrhosis. We examined the prevalence of advanced liver disease in people with type 2 diabetes and analysed the effectiveness of liver function tests (LFTs) as a screening tool. Methods: Participants (n = 939, aged 61–76 years) from the Edinburgh Type 2 Diabetes Study, a randomly selected population of people with type 2 diabetes, underwent abdominal ultrasonography. Hyaluronic acid (HA) and platelet count/spleen diameter ratio (PSR) were used as non-invasive markers of hepatic fibrosis and portal hypertension. Subjects were screened for secondary causes of liver disease that excluded them from a diagnosis of NAFLD. The efficacy of LFTs [alanine aminotransferase (ALT) and gamma-glutamyltransferase (GGT)] in screening for liver disease was determined. Results: Cirrhosis was identified by ultrasound in four participants (0.4%). Ten (1.1%) had evidence of portal hypertension (PSR < 909), and two (0.2%) had hepatocellular carcinoma. Fifty-three participants (5.7%) had evidence of hepatic fibrosis (HA > 100 ng/ml in the absence of joint disease); a further 169 had HA > 50 ng/ml. In participants with NAFLD-related fibrosis (HA > 100 ng/ml), 12.5% had an elevated ALT level and 17.5% had an elevated GGT level. Conclusions: The prevalence of hepatic fibrosis and cirrhosis were lower than expected. The use of LFTs to screen for liver disease missed most cases of fibrosis predicted by raised HA levels.
- White matter abnormalities in primary Sjogren syndrome Objective: To describe the main characteristics of patients with primary Sjögren syndrome (SS) and white matter abnormalities (WMA) seen by a specialist SS unit. Methods: The study cohort included 321 consecutive patients fulfilling the 2002 classification criteria for primary SS. We retrospectively analyzed the results of neuroimaging studies performed in patients who presented with neurological symptoms. Patients were further evaluated by three neurologists to determine fulfillment of the McDonald criteria for the diagnosis of multiple sclerosis (MS). Results: Fifty-one (16%) patients had at least one neuroimaging study, and 25 of these had WMA. WMA were classified as vascular pathological changes in 21 patients: 10 had multiple small focal lesions, 7 had beginning confluence of lesions and 4 had diffuse involvement of the entire region. WMA were classified as inflammatory/demyelinating lesions (MS-like) in 4 patients who fulfilled the MRI Barkhof criteria. Patients with inflammatory/demyelinating lesions were younger (53.7 vs. 73.5 years, P = 0.001) and had a lower frequency of hypertension (25% vs. 86%, P = 0.031) and altered glomerular filtration rate (0% vs. 70%, P = 0.047) in comparison with patients with vascular lesions. The multivariate age–sex adjusted model including the seven variables which were statistically significant in the univariate analysis (antimalarial therapy, leukopenia, anti-La/SSB antibodies, diabetes, hypertension, metabolic syndrome and HDL-c levels) identified hypertension (P = 0.019) and HDL-c levels (P = 0.032) as independent predictors of WMA in primary SS patients. Conclusion: Neuroimaging studies disclosed WMA in 49% of patients with primary SS and suspected neurological involvement. WMA were identified as vascular pathological changes in 80% of the patients, and hypertension and HDL-c levels as predictive factors for this association.
- The prognostic significance of early and late anaemia in ... Background and aim: Anaemia in acute coronary syndrome (ACS) is a common and strong independent risk factor but it is unknown whether early anaemia is transient or whether it persists over the subsequent weeks. We also sought to evaluate whether late anaemia carries the similar prognostic significance as baseline anaemia. Another unknown is whether haemoglobin improves risk stratification over and above the GRACE score. Design and methods: Haemoglobin levels were prospectively measured in 448 consecutive patients presenting with ACS and at 7-weeks follow-up. Cardiovascular endpoints were defined as death or acute myocardial infarction (AMI) over a median duration of 30 months (range 1–50). Results: The prevalence of anaemia on admission was 20% and this increased to 40% at 7-weeks follow-up. New anaemia occurred in 31% of patients. Baseline anaemia predicted CV endpoints independent of the admission GRACE (Global Registry of Acute Coronary Events) score [adjusted RR 2.54 (95% CI 1.73–3.71)]. Anaemia at 7-weeks follow-up was also a strong predictor of adverse outcomes [adjusted RR 1.67 (95% CI 1.04–2.69)]. Patients with persistent anaemia at 7 weeks were at an increased risk of death or AMI compared to those with persistently normal haemoglobin [unadjusted RR 3.58 (95% CI 2.04–6.29)]. Conclusion: In ACS, the prevalence of anaemia doubles from admission to 7-weeks follow-up (40%). Not only did baseline anaemia predict long-term prognosis independent of the admission GRACE score, but haemoglobin at 7-weeks post-ACS was also a simple independent predictor of adverse prognosis.
- A national analysis of complications following hemiarthro... Background: There is emerging evidence that patients with fractured neck of femur (FNOF) aged >85 years have different demands on a health-care system when compared to younger patients. Aim: We sought to better quantify this in terms of comorbidity and complication rates. Design: Retrospective review of national database. Methods: Data on all patients who underwent hip hemiarthroplasty for FNOF between January 2005 and December 2008 were extracted from the English hospital episode statistics database. Results: There were 41 770 patients aged 65–84 years and 35 321 patients aged ≥85 years. The older cohort was less likely to have diabetes, chronic obstructive pulmonary disease and rheumatoid arthritis. However, they exhibited a significantly higher risk of lower respiratory tract infection [odds ratio (OR) = 1.58, 95% confidence interval (CI) 1.50–1.67)], myocardial infarction (OR = 1.67, 1.52–1.83) and acute renal failure (OR = 1.54, 1.40–1.70) within 30 days of surgery with an inpatient mortality risk at 90 days, double that of the younger age group. Length of stay (LoS) was significantly longer in patients >85 years compared to younger patients (median 18 days vs. 15, P < 0.001). Conclusion: Patients aged ≥85 years admitted for FNOF were found to have a lower incidence of major chronic disease but exhibited a greater incidence of acute events following hemiarthroplasty and their LoS was increased. Targeted medical interventions that focus upon this susceptible patient group may help reduce morbidity and improve survival.
- Bradyarrhythmia as a presenting feature of subclinical hy...
- The relative afferent pupillary defect: its role in the d...
The American Journal of Medicine
- Changing US and World Demographics: Consequences for the ... Demographics is a field of study in which statistical characteristics of a population are followed over a period of time. Commonly, demographic data are used in analyses involving fields such as sociology, public policy, and marketing. Characteristics that are followed often include gender, age, survival, a variety of disabilities, urbanization, socioeconomic factors, educational level, and many other variables. Demographic changes in a population can have major consequences for healthcare delivery and planning. For example, if the population in a specific country demonstrates a demographic trend for increasing numbers of geriatric individuals, this will have a major impact on the demand for inpatient hospital and rehabilitation services because this age group has a high rate of use for such services.
- Thrombolytics and Vena Cava Filters Decrease Mortality in... SEE RELATED ARTICLES pp. 465, 471, and 478.
- Caveat Promisor: The Potential Pitfalls of Clinical Guara... In George Bernard Shaw's acerbic depiction of the medical profession, an unscrupulous physician reveals that “just two words” had brought him financial success: “Cure Guaranteed.” It is common knowledge that such an advertising scheme would be considered unethical. The American Medical Association (AMA) Code of Ethics prohibits outcome-contingent treatment fees as “creating unrealistic expectations of medicine and false promises to consumers.” Elsewhere, AMA policy reaffirms that “the results of medical services cannot be guaranteed.”
- Salt and Hypertension: Is Salt Dietary Reduction Worth th... Abstract: In numerous epidemiologic, clinical, and experimental studies, dietary sodium intake has been linked to blood pressure, and a reduction in dietary salt intake has been documented to lower blood pressure. In young subjects, salt intake has a programming effect in that blood pressure remains elevated even after a high salt intake has been reduced. Elderly subjects, African Americans, and obese patients are more sensitive to the blood pressure-lowering effects of a decreased salt intake. Depending on the baseline blood pressure and degree of salt intake reduction, systolic blood pressure can be lowered by 4 to 8 mm Hg. A greater decrease in blood pressure is achieved when a reduced salt intake is combined with other lifestyle interventions, such as adherence to Dietary Approaches to Stop Hypertension. A high salt intake has been shown to increase not only blood pressure but also the risk of stroke, left ventricular hypertrophy, and proteinuria. Adverse effects associated with salt intake reduction, unless excessive, seem to be minimal. However, data linking a decreased salt intake to a decrease in morbidity and mortality in hypertensive patients are not unanimous. Dietary salt intake reduction can delay or prevent the incidence of antihypertensive therapy, can facilitate blood pressure reduction in hypertensive patients receiving medical therapy, and may represent a simple cost-saving mediator to reduce cardiovascular morbidity and mortality.
- Evidence-based Use of Statins for Primary Prevention of C... Abstract: Three-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, commonly known as statins, are widely available, inexpensive, and represent a potent therapy for treating elevated cholesterol. Current national guidelines put forth by the Adult Treatment Panel III recommend statins as part of a comprehensive primary prevention strategy for patients with elevated low-density lipoprotein cholesterol at increased risk for developing coronary heart disease within 10 years. Lack of a clear-cut mortality benefit in primary prevention has caused some to question the use of statins for patients without known coronary heart disease. On review of the literature, we conclude that current data support only a modest mortality benefit for statin primary prevention when assessed in the short term (<5 years). Of note, statin primary prevention results in a significant decrease in cardiovascular morbidity over the short and long term and a trend toward increased reduction in mortality over the long term. When appraised together, these data provide compelling evidence to support the use of statins for primary prevention in patients with risk factors for developing coronary heart disease over the next 10 years.
- Amiodarone-associated Optic Neuropathy: A Critical Review Abstract: Although amiodarone is the most commonly prescribed anti-arrhythmic drug, its use is limited by serious toxicities, including optic neuropathy. Current reports of amiodarone-associated optic neuropathy identified from the Food and Drug Administration's Adverse Event Reporting System and published case reports were reviewed. A total of 296 reports were identified: 214 from the Adverse Event Reporting System, 59 from published case reports, and 23 from adverse events reports for patients enrolled in clinical trials. Mean duration of amiodarone therapy before vision loss was 9 months (range 1-84 months). Insidious onset of amiodarone-associated optic neuropathy (44%) was the most common presentation, and nearly one third were asymptomatic. Optic disk edema was present in 85% of cases. Following drug cessation, 58% had improved visual acuity, 21% were unchanged, and 21% had further decreased visual acuity. Legal blindness (<20/200) was noted in at least one eye in 20% of cases. Close ophthalmologic surveillance of patients during the tenure of amiodarone administration is warranted.
- Improving the Preventive Care of Asplenic Patients Asplenia and hyposplenia increase the risk of fulminant sepsis by a variety of organisms. Vaccination against encapsulated bacteria and early administration of empiric antibiotics for febrile illnesses can reduce the risk of sepsis.
- From the Outside Looking In One cannot overstate the value of a detailed skin examination in the diagnosis of systemic disorders, including infectious diseases. This precept was demonstrated in the present case.
- Nonspecific but Significant Vague signs should not be overlooked, as they can on occasion, hint at a dire diagnosis. A 24-year-old serviceman complained about mild lower-back pain about 1 year before admission to our hospital. Initially, he visited an orthopedist, and plain radiography of the lateral thoracic and lumbar spine was performed. Several small irregularly-shaped calcifications located over the peritoneal region were interpreted as a nonspecific finding ().
- Thrombolytic Therapy in Unstable Patients with Acute Pulm... Abstract: Background: Data are sparse and inconsistent regarding whether thrombolytic therapy reduces case fatality rate in unstable patients with acute pulmonary embolism. We tested the hypothesis that thrombolytic therapy reduces case fatality rate in such patients. Methods: In-hospital all-cause case fatality rate according to treatment was determined in unstable patients with pulmonary embolism who were discharged from short-stay hospitals throughout the United States from 1999 to 2008 by using data from the Nationwide Inpatient Sample. Unstable patients were in shock or ventilator dependent. Results: Among unstable patients with pulmonary embolism, 21,390 of 72,230 (30%) received thrombolytic therapy. In-hospital all-cause case fatality rate in unstable patients with thrombolytic therapy was 3105 of 21,390 (15%) versus 23,820 of 50,840 (47%) without thrombolytic therapy (P<.0001). All-cause case fatality rate in unstable patients with thrombolytic therapy plus a vena cava filter was 505 of 6630 (7.6%) versus 4260 of 12,850 (33%) with a filter alone (P<.0001). Case fatality rate attributable to pulmonary embolism in unstable patients was 820 of 9810 (8.4%) with thrombolytic therapy versus 1080 of 2600 (42%) with no thrombolytic therapy (P<.0001). Case fatality rate attributable to pulmonary embolism in unstable patients with thrombolytic therapy plus vena cava filter was 70 of 2590 (2.7%) versus 160 of 600 (27%) with a filter alone (P<.0001). Conclusion: In-hospital all-cause case fatality rate and case fatality rate attributable to pulmonary embolism in unstable patients was lower in those who received thrombolytic therapy. Thrombolytic therapy resulted in a lower case fatality rate than using vena cava filters alone, and the combination resulted in an even lower case fatality rate. Thrombolytic therapy in combination with a vena cava filter in unstable patients with acute pulmonary embolism seems indicated.
European Journal of Internal Medicine
- Editorial Board
- Contents
- The search of a common path in internal medicine This issue of the European Journal of Internal Medicine features a paper by Porcel and co-workers , which has the major merit of opening a fruitful discussion on the mission and competencies of Internal Medicine in Europe. Our journal is willing to take the opportunity to publish as Letters to the Editor contributions to such discussion (no longer than 1000 words and 5 references if needed) stemming from the national societies of Internal Medicine and related academic groups of Europe, and to act as collector of this process which starts with the publication from the Spanish internists.
- From stress to functional syndromes: An internist's point... Abstract: In this brief review we address schematically the relationship between two emerging issues in clinical medicine: stress and functional syndromes. It is becoming increasingly clear that they demand a multidimensional approach, considering simultaneously elements of behavioral therapy with traditional pharmacological treatment, guided by a better physiopathological understanding including autonomic assessment. New techniques, based on innovative analysis of continuous segments of electrocardiogram and non invasive arterial pressure recordings capable to extract hidden oscillations, provide quantitative indices of sympathetic and vagal modulation of the cardiovascular system. This more complete diagnostic process facilitates explanation of symptoms and reassurance of patients, based on functional evidence. The described clinical approach implies in addition an active collaboration of patients requiring the implementation of a creative alliance. Physical exercise, eating habits and muscular–mental relaxation are combined with pharmacological tools as needed.
- Respiratory High-Dependency Care Units for the burden of ... Abstract: The burden of acute respiratory failure (ARF) has become one of the greatest epidemiological challenges for the modern health systems. Consistently, the imbalance between the increasing prevalence of acutely de-compensated respiratory diseases and the shortage of high-daily cost ICU beds has stimulated new health cost-effective solutions.Respiratory High-Dependency Care Units (RHDCU) provide a specialised environment for patients who require an “intermediate” level of care between the ICU and the ward, where non-invasive monitoring and assisted ventilation techniques are preferentially applied. Since they are dedicated to the management of “mono-organ” decompensations, treatment of ARF patients in RHDCU avoids the dangerous “under-assistance” in the ward and unnecessary “over-assistance” in ICU. RHDCUs provide a specialised quality of care for ARF with health resources optimisation and their spread throughout health systems has been driven by their high-level of expertise in non-invasive ventilation (NIV), weaning from invasive ventilation, tracheostomy care, and discharging planning for ventilator-dependent patients.
- Fibrates: Therapeutic potential for diabetic nephropathy? Abstract: Despite intensive glucose-lowering treatment and advanced therapies for cardiovascular risk factors, such as hypertension and dyslipidaemia, diabetes mellitus with its macro- and microvascular complications remains a major health problem. Especially diabetic nephropathy is a leading cause of morbidity and mortality, and its prevalence is increasing. Peroxisome proliferator-activated receptor-α (PPAR-α), a member of a large nuclear receptor superfamily, is expressed in several tissues including the kidney. Recently, experimental data have suggested that PPAR-α activation plays a pivotal role in the regulation of fatty acid oxidation, lipid metabolism, inflammatory and vascular responses, and might regulate various metabolic and intracellular signalling pathways that lead to diabetic microvascular complications. This review examines the role of PPAR-α activation in diabetic nephropathy and summarises data from experimental and clinical studies on the emerging therapeutic potential of fibrates in diabetic nephropathy.
- Statin induced myotoxicity Abstract: Statins are an effective treatment for the prevention of cardiovascular diseases and used extensively worldwide. However, myotoxicity induced by statins is a common adverse event and a major barrier to maximising cardiovascular risk reduction. The clinical spectrum of statin induced myotoxicity includes asymptomatic rise in creatine kinase concentration, myalgia, myositis and rhabdomyolysis. In certain cases, the cessation of statin therapy does not result in the resolution of muscular symptoms or the normalization of creatine kinase, raising the possibility of necrotizing autoimmune myopathy. There is increasing understanding and recognition of the pathophysiology and risk factors of statin induced myotoxicity. Careful history and physical examination in conjunction with selected investigations such as creatine kinase measurement, electromyography and muscle biopsy in appropriate clinical scenario help diagnose the condition. The management of statin induced myotoxicity involves statin cessation, the use of alternative lipid lowering agents or treatment regimes, and in the case of necrotizing autoimmune myopathy, immunosuppression.
- Chikungunya fever Abstract: Chikungunya fever (CF) is an acute illness caused by Chikungunya virus (CHIKV) belonging to the alphavirus genus of the Alphaviruses (Togaviridae) family. The virus is transmitted by Aedes mosquitoes. CF is primarily tropical disease occurring in Africa, Asia and Indian Ocean islands but in the last decade an outbreak of CHIKV autochthonous infections were reported in Italy and France. It is associated with viral genome mutations facilitating transmission of the disease by Aedes albopictus, a mosquito occurring in several European countries.The CF is highly symptomatic, characterized by fever, cutaneuos rash and severe athralgia and arthritis. In some patients severe neurological or hemorrhagic manifestations occur. The disease is self-limiting but a part of the patients suffers from a long-lasting arthritis akin to rheumatoid arthritis.Treatment is only symptomatic. Prevention includes reduction of mosquito bite (mosquito net, repellent) or application of measures against mosquito larvae. Vaccination is not currently available but investigations are in progress.CF presents a significant worldwide health problem affecting in the last decade millions of person, and currently dangerous also for European countries.
- Herbal medicine, Chaplin, and “The Kid” Abstract: At variance with other largely safe complementary alternative medicines like homeopathy and acupuncture, which only carry the risk of inducing patients to shun effective treatment, herbal remedies are real, albeit impure, drugs and therefore fully capable of producing undesirable consequences if misused. The advantages they offer are uncertain since genuine evidence of efficacy and effectiveness is present in only a few cases. A result of this imbalance is that studies in this field are considerably more meaningful when they deal with untoward effects than with therapeutic uses. This disproportion has suggested to us the curious similarity with the situation portrayed in the film “The Kid” where the essential task of the protagonist (Chaplin) is to repair the windows his stone-throwing child has just broken.
- Association between venous and arterial thrombosis: Clini... Abstract: Venous and arterial thromboses have traditionally been regarded as separate diseases with different causes. However, recent epidemiological studies have documented an association between these vascular complications, probably due to the presence of more overlapping risk factors than previously recognized. This narrative review first focuses on the risk factors associated with both arterial and venous thrombotic events. In addition, it summarizes the more recent data on the risk of incident venous thromboembolism in patients with asymptomatic atherosclerosis or clinical manifestations of atherothrombosis, as well as on the risk of incident atherothrombotic events in patients with previous manifestation of venous thromboembolism. The potential clinical implications are also discussed.
Canadian Medical Association Journal current issue
- Everything in moderation, including vision [News]
- India moves to contain organ donation havoc [News]
- Obtaining sustenance through spirits [News]
- Former Supreme Court justice blasts minimum sentences for...
- Feds target redundancies and waste at Health Canada [News]
- Unhealthy behaviours influenced by genes and environment ...
- Is "Obamacare' suddenly on the ropes? [News]
- The road map to better hospitals [News]
- Young women with breast cancer genes face tough choices [...
- Caught in lead recall limbo [News]
ACP Internist: Current Contents
- Building the medical home starts in school Four medical schools revamped their residency programs to include concepts of the patient-centered medical home. The changes resulted in teamwork, continuity of care, and more intense clinical rotations.
- HIV comes of age as disease of mid-to-late life Protease inhibitors revolutionized HIV management, morphing it from a death sentence to a chronic, manageable condition. Medical issues have since grown more complex as doctors consider how HIV interacts with aging, and how aging interacts with these sometimes toxic drugs used to control the virus.
- It's tough to navigate return from cancer care to primary... An Institute of Medicine report suggests that patients are becoming lost in transitions between oncology and primary care. Educating physicians is a key to overcoming many of the barriers.
- Evaluating what is important about performance measures Connecting with the patient and improving their health should be the key factor behind implementing performance measures in the health care system.
- What should physicians contribute to deficit reduction? ACP has proposed that Congress create a national, physician-led initiative to promote high-value care, promote research into comparative effectiveness, and reduce the needless expense of defensive medicine.
- ICD-9 diagnosis codes updated for 2011-2012 The latest annual update of the ICD-9 diagnosis codes outlines many new codes that will be common to internal medicine. A comprehensive list outlines what's new.
- Options to secure e-mails Numerous options are available to make e-mail communications to patients more secure.
- From the MKSAP case studies A 59-year-old man is evaluated for a 4-day history of progressive worsening of fatigue, forgetfulness, constipation, excessive thirst and increased urination. He has no pain. Based upon the findings of a physical exam and lab results, what is the most likely diagnosis?
- Nominees named for College Officer and Regent positions The Governance Committee of ACP places in nomination a list of candidates.
- Obituaries A list of former ACP leaders who have passed.
ACP Internist
- Rumors of a doc's demise ... A loyal reader sent me this very interesting letter.Dr. Dowden apparently mailed it to all of his patients, current and former. [Note: This is not an April Fool's joke.]Not a very subliminal message. Translation:"Rumors of my retirement are greatly exaggerated. Fear not, loyal patients. Yet should you be hesitating on having me render you more beautiful, tarry no further; else you may find yourself out of luck ... "I wonder if by this method he'll drum up business and retire in a blaze of cosmetic glory.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.
- Can someone tell me why I should care about EINSTEIN-PE? EINSTEIN-PE was published in the April 5 edition of the New England Journal of Medicine, the place to find cutting edge, non-inferiority, open-label trials, written and sponsored mostly or fully by pharmaceutical companies.What I learned from reading this article is that rivaroxaban is a great generic drug name, as I'm not sure what syl-LABUL to put the em-PHASIS on: RIVA-ro-xaban or is it riva-ROXA-ban? It really doesn't matter, but it's one reason that I'm not rushing out to find converts to its cause.In this day in age of evidence-based medicine I'm not sure why we as internists should have to put up with an open-label non-inferiority trials to guide our prescribing habits. They might as well have glued $20 bills or coupons to a local Sushi restaurant in the journal. I've heard that there is a worldwide shortage of placebo, rising cost of sugar because of the cost of gas. It must be at the heart of this.It turns out that rivaroxaban is not worse than enoxaparin and warfarin, which many of us are very familiar with and our clinics can easily manage. For example, look at the study's Kaplan-Meier curves minus the grossly magnified inserts that they published. Based on these curves I can safely say that I see no clinically meaningful endpoint to suggest that I should jump ship quite yet.For the sake of argument, let's do the math. For the primary outcome of recurrent nonfatal venous thromboembolism the absolute rate reduction of rivaroxaban vs. enoxaparin/warfarin was 0.3 percentage points (based on the absolute event rate, not the hazard ratio.) The number needed to treat is 333. It appears that there is a 1.1 percentage point difference in first major or clinically relevant nonmajor bleeding episode the winner here, rivaroxaban. Number needed to prevent said bleeding episode of 91.Maybe I'm just against these oral direct thrombin inhibitors and factor Xa inhibitors because they take all of the fun out of warfarin management.I'll continue to prescribe rat poison. I'm good at it, it's cheap, and it works.Addendum: Finally, in addition to actually monitoring all 4,900 patients for 6 months of therapy they just stopped when they felt (had proven statistical utility ... er, power) that enough patients had recurrent events. So we really don't know what truly happens when you put people almost 5,000 people on this med over the course of 6 months.Justin Penn, MD, ACP Associate Member, attended medical school at the University of Washington School of Medicine and trained in internal medicine at the University of Rochester, where he is serving as Chief Resident. This post originally appeared at his blog, Musings of an Internist.
- QD: News Every Day--Biggest fear of malpractice suits is ... Nearly 80% of malpractice verdicts are in favor of the doctor, while less than 3% of cases against internists and medicine-based subspecialists ultimately reach a trial verdict.A research letter published online in Archives of Internal Medicine looked at more than 10,000 cases from 2002 to 2005.From all claims, 55.2% of all specialties resulted in litigation, while the rate among internists and medicine-based subspecialists was slightly lower, at 53.5%.Cases were dismissed by the court 54.1% of the time across all specialties, but more often among cases against internists and medicine-based subspecialists, at 61.5%. With the outcomes so slanted, it's more often the time tied up in litigation, the authors wrote. The mean time required to close a malpractice claim was 19 months, with the mean for litigated claims being just over 25 months."While most claims were ultimately decided in a physician's favor, that resolution came only after months or years," the authors wrote. "The substantial portion of litigated claims that are not dismissed in court and the length of time required to resolve litigated claims more generally may help explain why malpractice claims undergoing litigation are an important source of concern to physicians."
- Board exams don't resemble real practice and waste my time I took the day off today. I'm taking my recertification exam tomorrow, and I like to go into these things well-rested. I got up with PalKid, made her breakfast, had a leisurely cup of coffee and enjoyed a ride to school with a loquacious second-grader. I violated one of my primary rules for before-the-test days and did a little studying at the coffee shop. It's still hard for me to take this exam terribly seriously. I was reminded of this when I dropped by my office to get a little work done, work that bore little resemblance to what I will encounter on the board exams.Internists trained after the 1980s are required to re-certify every 10 years. It's not a stretch to say that most internists find the process time-consuming, expensive, and largely irrelevant. As medical knowledge has expanded, the practice of medicine has become very subspecialized. There is little need for me to know the current regimen for the treatment of multiple myeloma. It's enough to know how to diagnose it and to know some of the consequences of treatment. I don't manage kidney dialysis, so the ins and outs are, to me, not terribly useful. I'm not a brain surgeon (just ask anyone) so I don't really need to know the best surgical approach for a pituitary macroadenoma.The recertification process takes at least a year or so. One of the more useful aspects is the requirement that I do "learning modules," sets of questions that help me review important topics (but that are explicitly labeled as being NOT board review questions, wink-wink). Of course, I could do those modules in the course of my yearly continuing medical education. The most onerous bit is the "practice improvement module." I chose diabetes, a condition familiar to my practice.It required my patients to fill out surveys, for me to enter data from a couple of a dozen charts, go through several other bits, re-review my charts, and at the end of the month or so it took, time was taken away from my life and I learned something I already knew: It's hard to take care of diabetics when they are real people. Not every patient can reach the standards we've set, nor should they, depending on their circumstances.Tomorrow I show up at a testing facility with two forms of photo ID and must submit to "palm vein biometric analysis." Then I have to leave everything outside the room: my two forms of photo ID, my wristwatch, my wallet, any pens or pencils, and God-knows what else. Probably my belt and shoe laces. No scratch paper for me! (Apparently they provide some sort of small dry-erase board or something to jot ideas on.)Is this expensive, humiliating, time-consuming effort useful? Who knows? There aren't many useful outcomes measures in the literature. It's not clearly known whether the current process makes better doctors. It is clear, to those of us in daily practice, that the process was not designed by practicing internists, at least not those who work full-time in the busy primary care environment. It also fails to recognize the technology available to modern physicians. We no longer rely exclusively on our memory when evaluating patients. We have quick and easy access to web-based references and to our colleagues. The board exams reflect our ability to recall rote knowledge, something most of us are quite good at, but it encourages behavior that is not good for our patients. Our access to information helps our patients, keeps us from making mistakes based on faulty memory.I'm not terribly concerned. I do well on standardized exams, but I realize that this little talent has little to do with my daily practice.It's pretty embarrassing that we allow our colleagues to put us through this. The exam is the least offensive bit. The entire process is a drain on the limited time and resources of a primary care physician. The process could be simplified by having docs do question sets at home, with access to reference sources, the way we actually work in real life. Throw a dozen of those at me and I'll probably learn more medicine in two months than I have in two years of my current recertification process.(Here's an example of more realistic questions you'll never see.)Did I mention that we get a TSA-style wanding?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, White Coat Underground. The 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.
- Plumbers, ninjas and doctors When my wife told me about her encounter with the plumber, all I could think was: "What a jerk!" Then I was hit with an eerie sense of familiarity. OK, it wasn't exactly eerie, but there was some creepy music in the background.We had a shower fixed about a year ago, costing us a bunch of money. I would do it myself, but past experience gave me frightening images of water dripping through the ceiling, and bathrooms falling in to the middle of our garage. I still awake with cold sweats from previous plumbing experiences. So we found a plumber with good recommendations on Angie's List, so we thought we were safe. But after paying a whole lot of money, we were left with a faucet that seemed like it was made out of a plastic-metal alloy and took about half a turn to get any cold water. We were afraid to call the guy back, however, given how much he charged us for our previous encounter. Despite the cheap faucet, we had no leaks and experienced no sudden appearances of bathrooms in our garage.Then last week my daughter told us the shower wouldn't turn off. Through the fine art of faucet jiggling I was able to get the shower to stop (and she was quite impressed by my mad skills). But another night's shower had the same complaint from my daughter, and my skills were not as mad as I was. Since it had been about a year since our last repair, and since the faucet seemed chintzy, we called back the same plumber and he came over to assess the damage. It seemed like it was his fault.The plumber, being the trained craftsman he was, quickly found the source of the problem: us.My wife explained what happened, as well as the elbow pain we all experience turning the cold water, and he shook his head. He noticed the caulking around the cold water faucet was missing, and told my wife that someone had "obviously" done something to that faucet. When my wife explained that my mortal fear of plumbing (and her mortal fear of my plumbing) made this an impossibility, he looked at her with a condescending skepticism. It seemed "obvious" to him that either my wife was not telling the truth, or that a plumbing ninja had infiltrated our bathroom to remove the caulk without our knowledge.Things got worse when my wife suggested that the hardware installed wasn't very high quality. He seemed offended at the suggestion that he would use anything but the best. How could a mere mortal non-plumber suggest that the shower that she uses every single day is anything but the best? Her suggestion that it shouldn't take so much turning to get cold water was clearly a statement of ignorance, or a fabrication designed to slander this highly trained professional.The good news was that it was just the white cartridge thingy that needed replacement and so it took only $75 to get rid of this jerk and get our shower back to its previous sorry state. I suspect that because the faucets have so much play in them, my daughter cranked them harder than she should to turn them off and so damaged the cartridge thingy. Either that, or the plumbing ninja was at doing more than going after the caulking. I shouldn't think about it too hard, though, because I've actually created leaks in pipes by prolonged contemplation.Unfortunately, this encounter with the demigod of plumbing reminds me a lot of what my patients get when they see certain specialists. Several aspects of my wife's experience are eerily similar (there goes that music again).The plumber's reality trumped anything my wife experienced. Despite the fact that she showers in it every day, she was not given any credit for her own experience. The plumber's self-centered view of the universe made it impossible to consider my wife may know something about the shower. In the same way, patients are treated like they simply can't be having the symptoms they are having because it doesn't make sense to the highly-trained and extremely intelligent doctor specialist. My wife's suggestion that the plumber may be wrong was something she was made to feel guilty about. It's not just that she was wrong in her reality experience; she should feel shame for experiencing anything the plumber said wasn't true. This is exactly the same as my patients who visit doctors with the same reality-distortion field. They are bad people for experiencing what they do. Our experience with the plumber makes us want to avoid further encounters with members of the profession, and to seek alternatives if possible. Why is it such a mystery that patients seek alternative medicine when they are made to feel stupid when they go to the doctor? Nobody wants to be made to feel guilty for symptoms they don't want in the first place. We feel like our ignorance (and mortal fear) of plumbing is an opportunity this guy used to pass cheap material off on us for a premium price. My patients come back from specialist, ER, or hospital visits with enormous bills and often feeling they are not listened to. I don't mean to pick on specialists, as there are plenty of primary care docs who treat patients in the same condescending way. Our profession has a bad reputation that we've been working hard to earn, so I have to share the credit with doctors of all kinds. I have patients actually tell me that I am "the first doctor who has ever listened to me." While I think that is an exaggeration, the perception is rampant: We docs are arrogant know-it-alls who charge too much.So what next? I am going to Angie's List and am going to write a bad review of our experience with this guy. I owe it to other plumb-o-phobes so they can steer clear of this doink. I can't do this without hearing the shrill cries of doctors detesting their patients who give them bad online reviews. How can I complain about this guy? What do I know about plumbing? I should just be glad I don't have a shower in my garage!We need to wise up. Some of this arrogance stems from a system which turns patients into E/M and ICD-9 codes, forcing doctors to pay more attention to documentation requirements and achieving "meaningful use" than to what the patient says. Doctors are sick and tired of the system, and sometimes facing a patient who blames us for the system that makes our lives hell gets under our skin. But nothing excuses arrogant reality-distortion fields like this plumber and many docs emit.Nobody wants to see a jerk.After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.
- 260 words about 'eating mostly plants' The notion that eating meat might be bad for us is tough to swallow for a generation that has drunk deep of the "low carb" Kool-Aid. Even if eating meat were good for people, too much focus on it would be ill-advised for a population of 7 billion of us. The environmental costs of eating animals are an order, or even orders, of magnitude higher than eating plants.But can it be that eating meat is truly bad for the health of the great-great-granddaughters and sons of hunter-gatherers? Yes. Because just as we "are what we eat," so too are the animals we eat. The diets of most animals providing our meat are nothing like those of THEIR ancestors, and thus neither is their flesh. Most of our meat is higher in calories, harmful varieties of fat, and environmental contaminants that get concentrated as they move up the food chain.Finally, what we eat more of has implications for what we eat less of. Eating "more" meat means eating a lower proportion of calories from plants, vegetables, fruits, nuts, seeds, beans, lentils, whole grains, which are decisively associated with better health. To some extent, meat consumption contributes to adverse health outcomes, to some extent it "muscles" out of the diet foods that defend against them.Eating some meat, preferably from lean, well-fed, well-exercisedand kindly tended animals is assuredly consistent with human health. But the health of humans and the planet argue consistently for Michael Pollan's excellent and pithy advice: Eat food, not too much, mostly plants.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--CDC says team approach better control... Physician-led teams provide more effective care for controlling blood pressure, reports the CDC's Community Preventive Services Task Force.About one in three adults in the United States has hypertension, and less than half have it under control. If all hypertensive patients could reach the goals specified in current clinical guidelines, it might save 46,000 deaths each year, as well as medical costs of $131 billion and lost productivity costs of $25 billion. The Task Force recommends team-based care based on evidence from 77 studies of nurses and pharmacists working in collaboration with primary care providers.Each team consisted of the patient and a primary care provider, with most adding a pharmacist, nurse or both. The estimates for improved systolic and diastolic blood pressure were similar in the studies that added a nurse or a pharmacist. The estimated proportion of patients with controlled blood pressure was much higher when a pharmacist was added.In four of the 28 studies, team-based care was implemented without a nurse or a pharmacist, but with added professionals such as community health workers and dietitians. Blood pressure improvements in these studies were small, however.
- 3 ways that doctors make decisions I hope to write regularly on doctors' decision-making. This first installment concerns types of evidence-based studies. Later, I will talk about how and whether doctors actually use such evidence to make decisions.There are a number of kinds of evidence-based advice which doctors can use to make decisions. The differences among them are instructive.1. Individual journal articles. These can present findings from a single trial. The potential biases are multiple. Not all findings get published (publication bias, i.e. we never find out about the results which do not support the hypothesis). Many results are never reproduced. To quote one widely read study, "studies that report positive or significant results are more likely to be published and outcomes that are statistically significant have higher odds of being fully reported." Some studies have to be retracted later by the journal which publishes them.2. Reviews. These can be of many kinds. A narrative review recounts in a summary form the findings of a number of articles. The summary is susceptible to bias from many factors: which articles are chosen, what emphases are given, which author is doing the review. For that reason, some people prefer a ...3. Systematic review. This combines research articles on a given topic according to strict definitions made a priori. Then the results from these individual articles are combined only if they are comparable, i.e. applying to the same population or disease. Some of the time individual results can be merged in a statistical way, called a meta-analysis. I work on a number of these; they have their own problems (the link is from an orthodontics journal but the issues are generally applicable). 4. Guidelines. Using the above reviews, a group of experts, often physicians, draft official recommendations for a given disease, group of diseases, or use of a given medication or procedure. But guidelines are only as good as the evidence they are based on, the applicability of the guidelines to the particular question that is being considered. Is the patient from the population that was studied? Is the clinical condition the same? Was there any bias that might have affected the results. To take one example of a well-done review, the American Academy of Neurology and the American Headache Society recently published Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults. Even such a guideline, however, comes with weaknesses. For some of these we can quote the authors. While good-quality evidence does support the effectiveness of certain medications for treating migraines, "evidence is unavailable to help the practitioner choose one therapy over another." Another sort of weakness was also reported by these authors, but in a different way, in an often-ignored paragraph at the end of the article. For those that can't read the small type, these are disclosures of possible conflicts of interest. Nearly all the authors have received honorariums from a number of pharmaceutical companies. I don't think this completely obviates the recommendations, but it might if we look closely enough. This is why, to my way of thinking, any such guidelines need to be either free of conflict of interest or ensure balanced conflicts of interests among the writers.Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.
- Choices In the last hour, I suddenly became overwhelmed with just how many choices we make in a day. We choose whether or not to wake up in the morning to drag ourselves to school [some might argue that this isn't a choice ... but let's just go with it]. We choose what to eat when we're hungry. We choose which lane to drive in. We choose how we spend our time [such as right now, I am actively choosing not to study]. In life, we make a lot of choices that we don't think twice about because for the most part, they are trivial.But if you really think about it, some everyday choices we make affect those around us. Something as simple as smiling at a stranger as you hold the door open could be the highlight of someone's day. Cutting someone off as you merge into another lane could ruin the rest of that person's day. Sometimes, I think we forget just how interconnected we all are; most of the time I think I am just minding my own business and living in my own little world, but there's no such thing. We all end up influencing another human's life at some point in time, whether we acknowledge it or not.In medicine, our choices hold even more weight. This thought is exciting and chilling all at once; our choices can lead to bringing a new life into this world or ending one prematurely. Our words can tear a family apart or bring tears of joy to a patient. Our actions truly impact the life of our patient, whether we like it or not.This is the path we chose. We want to help people. We want to heal people. But in the end, there is no escaping the reality that we won't always be right. Most of the time, there is no such thing as black and white; there is just an expanse of gray that will only morph into clarity retrospectively.Amanda Xi is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Ann Arbor, Mich. She has a Bachelor of Science in Engineering [Biomedical Engineering] and Master of Science in Engineering [Biomedical Engineering, again] from the University of Michigan. This post originally appeared at her blog, "And Thus, It Begins," which chronicles her journey through medical training from day 1 of medical school.
- The outlier's message, and evolutionary science in breast... This past week I read several attitude-altering articles about breast cancer.The first lesson, if I might call it that, in the way an oncologist can learn from variations in her patients' pathology and clinical outcomes comes from the case of Katherine Russell Rich, who died last week at the age of 56. As reported by Katherine O'Brien in the I Hate Breast Cancer Blog, Rich lived with metastatic breast cancer for 18 years. That's phenomenal, was my first reaction to this news. The prognosis for metastatic breast cancer is said to be around 3 years, and Rich lived for 18 years beyond her tumor's recurrence with stage IV disease.As sad and unsatisfactory as this outcome may seem, and it is, Rich's story offers hope for life beyond the 3 or 4 or 5 years some women with metastatic breast cancer pray, "ask" or otherwise bargain for, fingers-crossed.As she detailed in an O article, Rich's initial diagnosis came when she was 32 years old, in 1988. The New York Times, in an obituary, tells of her lumpectomy, chemo and radiation. In 1993 her cancer came back in bones including her spine. She had a bone marrow transplant, but the disease progressed. Ultimately, she coursed through various and some archaic hormone treatments.Along the way, she lost or quit a job in publishing, or both, and traveled to India, and authored two books . In a 2010 first-person story about her case, she told of updating her status--of being alive--at Breastcancer.org each year. She wrote: "... I tell the women how deeply I believe there's no such thing as false hope: all hope is valid, even for people like us, even when hope would no longer appear to be sensible."Life itself isn't sensible, I say. No one can say with ultimate authority what will happen--with cancer, with a job that appears shaky, with all reversed fortunes--so you may as well seize all glimmers that appear.My take, as an oncologist and former clinician, is that patients sometimes surprise you. Hard to know which woman will respond to a non-targeted treatment, or even a drug like an estrogen modulator, without trying. And I wonder--and this is speculative, but maybe, likely, the two together, doctor and patient, worked together to see what worked in Rich's case over nearly 2 decades, and what didn't work.If a drug helps, keep it going; if it hurts, stop. There are so many algorithms in medicine, and molecular tools, but maybe the bottom line is how the, one, your patient is doing.Which leads me to another post, by Dr. David Gorski, a breast cancer surgeon and researcher who blogs as Orac--what once was imagined as a fabulously capable information processor, at Respectful Insolence. He describes how tough it can be to define, and thereby target or destroy, any individual patient's breast tumor because the cancer cells are constantly changing. Within each woman's tumor, an evolution-like process is ongoing, leading to selection of treatment-resistant cells. This is not news in oncology; the concept has been understood for years as it applies to "liquid" tumors like leukemia, as he points out.In breast cancer, understanding the complexity of each case is more recent. Dr. Gorski considers a genetic analysis of 104 triple negative breast cancer (TNBC) cases presented at the recent AACR meeting and published last week in Nature: "... The 59 scientists involved in this study expected to see similar gene profiles when they mapped on computer the genomes of 100 tumours."But to their amazement they found no two genomes were similar, never mind the same. 'Seeing these tumours at a molecular level has taught us we're dealing with a continuum of different types of breast cancer here, not just one,' explains Steven Jones, co-author of this study."... TNBC is not a single disease. In fact, even an individual TNBC tumor is not a single disease. Tumor cells evolve as they proliferate, so that the cells in them are genetically heterogeneous. The cells growing in one area of a tumor can and often do harbor markedly different genetic mutations from the cells growing in another part of the tumor ..."The team found that each tumor displayed multiple 'clonal genotypes,' suggesting that the cancer would have to be treated as multiple diseases, rather than a single entity."So besides that there are distinct subtypes of breast cancer, those labeled as TNBC are diverse and contain variation within; each patient harbors sub-clones of malignant cells that, in principle, respond differently to treatment.Putting these links together ... The message from Katherine O'Brien, who lives with metastatic breast cancer and blogs about it, is that one outlier, like Katherine Russell Rich, can provide hope to other patients and, maybe, clues for scientists about why she lived for so long with metastatic breast cancer. The message from Orac, a physician-scientist blogger, is how hard it is to pinpoint an individual breast tumor's molecular aspects, because the disease is so mutable and diverse.The problem, and this reflects evolution in my thinking over a long while, is that published data--the gold standard, what supports EBM--are largely limited to findings based on trials of groups. We understand now, better than we did 10 or 20 years ago, that each patient's tumor is unique and can evolve over time, naturally or in response to therapy. Clinical trials, though rigorously planned and elaborately structured, are incredibly expensive and flip-floppy, disappointing overall.What I'm thinkingAlgorithms, except in the broadest sense, may not offer the optimal approach to cancer treatment. Maybe the median doesn't matter so much as we'd thought.Here's a retro idea: In 2012, maybe the ideal and most cost-effective oncology practice would blend low-tech observations, like findings on physical examination and how the patient's feeling, with occasional, high-tech analyses, like markers for genetic drift within a tumor. If doctors are well-trained and non-robotic, in either the literal or figurative sense, and if they lack conflict of interests regarding treatment decisions, they'd provide better, more effective and personalized treatments than what's typically offered based on evidence reached through elaborate, costly clinical trials of many patients with similar but non-identical cancers.This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology and as a patient who's had breast cancer.
AAFP News Now
- A Meaningful Discussion About Meaningful Use More than 43,000 health care professionals have collected more than $3 billion in meaningful use incentive payments, according to CMS. And I was pleased to learn this week during a May 15 meeting at the Office of the National Coordinator for Health Information Technology (ONC) that family physicians are leading efforts to upgrade medical record technology, and by far, are the largest recipients of meaningful use funds. That's not surprising, considering that we are involved with -- and often coordinate -- complex care that requires communication with subspecialists, hospitals and health plans.
- Fee-For-Service Is Here to Stay, For Now, Says Health Pol... The U.S. health care system will continue to rely on a fee-for-service payment model for at least the next eight to 10 years, making it incumbent on policymakers to work on fixing flaws in the for the short-term. That's the opinion of health policy expert Robert Berenson, M.D., a senior fellow at the Urban Institute, who spoke as part of a panel on Medicare physician payment during the Family Medicine Congressional Conference here May 14-15. "It is going to take us awhile to move to something new, and I would guess there will be parts of the country in which fee-for-service will be with us for a very long time," said Berenson. "We probably will not have the organization developed to take on new payment models and the collaboration and integration that most of these payment models envision in the near future."
- Congressional Representatives Provide Differing Views on ... If the Supreme Court rules that the Patient Protection and Affordable Care Act is unconstitutional, Congress will work on retaining certain provisions in the law that enjoy bipartisan support. That was one of the main messages delivered by Rep. Cathy McMorris Rodgers, R-Wash., in the keynote address at this year's Family Medicine Congressional Conference May 14-15 in Washington. McMorris Rodgers told the nearly 200 family physicians at the conference that Congress is trying to anticipate how the Supreme Court might rule on the Affordable Care Act. "Should the Supreme Court rule that any part of the health care (law) is unconstitutional, we (Congress) are prepared to move forward immediately to try and prevent some of the chaos in the marketplace," said McMorris Rodgers.
- Text Message Reminders Could Improve Vaccination Rates, S... Text messaging has the potential to improve vaccination rates in low-income urban settings, says a study recently published in . In a randomized, controlled trial involving more than 9,000 children and adolescents ages 6 months to 18 years, parents of children randomized to the intervention group received as many as five weekly immunization registry-linked text messages that provided educational information and instructions regarding Saturday immunization clinics.
- Health Care Could Save Billions by Reducing Waste in Six ... The U.S. health care system could save hundreds of billions of dollars each year in public and private health care expenditures by adopting strategies to reduce waste in six key categories that are major drivers of health care costs. That's the conclusion of an article by former CMS Administrator Donald Berwick, M.D., and Andrew Hackbarth, M.Phil., an assistant policy analyst at the RAND Corp., in . "In just six categories of waste -- overtreatment, failures of care coordination, failures in execution of care processes, administrative complexity, pricing failures, and fraud and abuse -- the sum of the lowest available estimates exceeds 20 percent of total health care expenditures," say the authors. "The actual total may be far greater."
- Working With Others Key to Successfully Transforming Our ... Good partners can make all the difference when transforming a practice. For example, one of the family physicians in my practice, Andrew Drabick, M.D., was so concerned about the obesity problem in our community that he led our efforts to open a weight loss clinic. Many of our patients found the extra help they needed, and we added an important revenue stream. One of my other partners, Stephen Moore, M.D., is passionate about practicing family medicine, but he has little desire to be involved in the business of medicine. Stephen puts his trust in others to make sure we are running a sound business. I also love being a family physician, but I have the interest in business that my partner lacks. Together, we provide balance to a practice that has expanded three times in a little more than five years.
- News in Brief: Week of May 14-18 This roundup includes the following news briefs: Download Free Guide on Maintaining Privacy, Security of EHRs; Study Documents Decline in Health Care Access for U.S. Adults; and FDA Warns Against Multiple Sclerosis Treatment.
- AAFP Cries Foul Over Prescription Requirements for OTC Me... Many FPs and their patients were surprised to learn in January that a provision in the Patient Protection and Affordable Care Act required a physician's prescription to use funds from tax-preferred health accounts to purchase OTC items. Now, the AAFP has joined with dozens of other organizations in calling on Congress to repeal the provision, which "increases costs to the health care system and places a new administrative burden on already overburdened physician offices," according to members of the Health Choices Coalition, of which the AAFP is a member. In an April 25 letter to the House Ways and Means Committee, the coalition said the provision has "resulted in unintended consequences to both physicians and patients."
- Fluoroquinolones May Increase Risk for Retinal Detachment... Before signing off on that prescription for a fluoroquinolone, family physicians may wish to consider an alternative, as yet another possible side effect has surfaced for patients who take these broad-spectrum antibiotics. According to a study published last month in , patients who take fluoroquinolones are at increased risk for retinal detachment.
Journal of Internal Medicine
- Treatment with anti-inflammatory drugs in community-acqui... Pneumonia exhibits a broad range of severity, from mildly symptomatic at one end to fulminant septic shock and death at the other. Although an adequate inflammatory response is necessary for the clearance of microorganisms, excessive inflammation can lead to on-going local and systemic damage. Because of this extended inflammatory response despite appropriate antibiotic therapy, as well as increasing antibiotic resistance, adjuvant therapy for pneumonia that can favourably modify the immune response has become an increasingly relevant approach to improve prognosis. Different adjuvant treatment options for pneumonia have recently been proposed. Promising treatment options include corticosteroids, statins, macrolides and Toll-like receptor antagonists. The aim of this review is to summarize the inflammatory response during pneumonia and discuss the current knowledge and future perspectives regarding the anti-inflammatory treatment options for patients with pneumonia.© 2012 The Association for the Publication of the Journal of Internal Medicine
- Dietary Fats and Coronary Heart Disease The relation of dietary fat to risk of coronary heart disease has been studied extensively using many approaches, including controlled feeding studies with surrogate endpoints such as plasma lipids, limited randomized trials, and large cohort studies. All lines of evidence indicate that specific dietary fatty acids play important roles in the cause and prevention of coronary heart disease, but total fat as a percent of energy is unimportant. Trans fatty acids from partially hydrogenated vegetable oils have clear adverse effects and should be eliminated. Modest reductions in CHD rates by further decreases in saturated fat are possible if saturated fat is replaced by a combination of poly- and mono-unsaturated fat, and the benefits of polyunsaturated fat appear strongest. However, little or no benefit is likely if saturated fat is replaced by carbohydrate, but this will in part depend on the form of carbohydrate. Because both N-6 and N-3 polyunsaturated fatty acids are essential and reduce risk of heart disease, the ratio of N-6 to N-3 is not useful and can be misleading. In practice, reducing red meat and dairy products in a food supply and increasing intakes of nuts, fish, soy products, and nonhydrogenated vegetable oils will improve the mix of fatty acids and have a markedly beneficial effect on rates of coronary heart disease.© 2012 The Association for the Publication of the Journal of Internal Medicine
- B-type natriuretic peptide in the evaluation and manageme... Objectives: The rapid and accurate diagnosis of heart failure in primary care is a major unmet clinical need. We evaluated the additional use of B-type natriuretic peptide (BNP) levels.Design: A randomized controlled trial.Setting: Twenty-nine primary care physicians in Switzerland and Germany coordinated by the University Hospital Basel, Switzerland.Subjects: A total of 323 consecutive patients presenting with dyspnoea.Interventions: Assignment in a 1:1 ratio to a diagnostic strategy including point-of-care measurement of BNP (n=163) or standard assessment without BNP (n=160). The total medical cost at 3 months was the primary endpoint. Secondary endpoints were diagnostic certainty, time to appropriate therapy, functional capacity, hospitalization and mortality. The final diagnosis was adjudicated by a physician blinded to the BNP levels.Results: Heart failure was the final diagnosis in 34% of patients. The number of hospitalizations, functional status and total medical cost at 3 months [median $1655, interquartile range (IQR), 850–3331 vs. $1541, IQR 859–2827; P=0.68] were similar in both groups. BNP increased diagnostic certainty as defined by the need for further diagnostic work-up (33% vs. 45%; P=0.02) and accelerated the initiation of the appropriate treatment (13 days vs. 25 days; P=0.01). The area under the receiver operating characteristics curve for BNP to identify heart failure was 0.87 (95% confidence interval, 0.81–0.93).Conclusions: The use of BNP levels in primary care did not reduce total medical cost, but improved some of the secondary endpoints including diagnostic certainty and time to initiation of appropriate treatment.© 2012 The Association for the Publication of the Journal of Internal Medicine
- No autoimmune safety signal after vaccination with quadri...
- Immune activation and increased IL-21R expression are ass... Objectives: Microbial translocation and chronic immune activation were previously shown to be associated with impairment of T cell functions and disease progression during infection with human immunodeficiency virus type-1 (HIV-1); however, their impact on B cell function and number remains unknown. By measuring markers of immune activation and molecules involved in apoptosis regulation, we have evaluated the association between microbial translocation and loss of memory B cells in HIV-1-infected patients.Methods: Markers of activation [the interleukin-21 receptor (IL-21R) and CD38] and apoptosis (Bim, Bcl-2 and annexin V) were measured in B cell subpopulations by multicolour flow cytometry. Levels of soluble CD14 (sCD14) and lipopolysaccharide (LPS), measures of microbial translocation, were determined in plasma. Purified B cells were also exposed in vitro to Toll-like receptor (TLR) ligands.Results: IL-21R expression was higher on cells from HIV-1-infected patients, compared to control subjects, with the highest levels in non-treated patients. An inverse correlation was observed between IL-21R expression and percentages of circulating resting memory B cells. IL-21R-positive memory B cells were also more susceptible to spontaneous apoptosis and displayed lower levels of Bcl-2. It is interesting that the levels of sCD14, which are increased during HIV-1 infection, were correlated with decreased percentages of resting memory B cells and high IL-21R expression. In the plasma of HIV-1-infected individuals, a correlation was found between sCD14 and LPS levels. TLR activation of B cells in vitro resulted in IL-21R up-regulation.Conclusions: Microbial translocation and the associated immune activation during HIV-1 infection may lead to high expression levels of the IL-21R activation marker on resting memory B cells, a feature associated with increased apoptosis and a reduced number of these cells in the circulation.© 2012 The Association for the Publication of the Journal of Internal Medicine
- Plasma procalcitonin and the risk of cardiovascular event... Objectives: A number of inflammatory biomarkers such as C reactive protein (CRP) are independent predictors of cardiovascular risk. The inflammatory biomarker procalcitonin (PCT) has previously been shown to be associated with coronary atherosclerosis and the metabolic syndrome. We evaluated the ability of PCT to predict future cardiovascular events in a population of apparently healthy individuals.Design: We measured plasma PCT levels in 3713 subjects with no previous history of cardiovascular disease, randomly selected from the Malmö Diet and Cancer cohort. The correlation between PCT concentration and the incidence of coronary events, stroke and cardiovascular death over a median follow-up period of 13.7 years was studied using a Cox regression analysis corrected for age, sex, CRP level, traditional risk factors and renal function.Results: Age and sex were strong determinants of PCT; the concentration of PCT was significantly higher in men than in women. PCT was associated with several of the established cardiovascular risk factors (CRP, hypertension, diabetes and renal function,) as determined by multivariate linear regression. Of note, PCT was inversely correlated with HDL and smoking. We found significant correlations between PCT levels, coronary events and cardiovascular death. However, these relationships lost statistical significance when the analysis was corrected for CRP and the traditional risk factors.Conclusions: This is the largest population-based prospective study to demonstrate a positive association between plasma PCT levels and cardiovascular risk in subjects with no previous history of acute cardiovascular events. However, the high degree of covariation between PCT and other cardiovascular risk factors limits the value of PCT as an independent cardiovascular risk predictor.© 2012 The Association for the Publication of the Journal of Internal Medicine
- Letter to the Editor: Response to Letter from Dr. Eroglu ...
- Bone marrow or peripheral blood stem cell transplantation... Background: No survival benefit of using blood stem cells instead of bone marrow has been shown in matched unrelated donor transplantation.Design and methods: In a retrospective registry analysis, we compared the use of blood stem cells (n=1502) and bone marrow (n=760) from unrelated donors in patients aged 18 to 60 years with acute myeloid leukemia undergoing myeloablative conditioning between 1997 and 2008. The blood stem cell recipients were older (P<0.01), had more advanced disease (P<0.0001) and received less total body irradiation (P<0.0001) and more anti-thymocyte globulin (P=0.01).Results: Recovery of neutrophils and platelets was faster with blood stem cells (P<0.0001). The incidence of acute graft-versus-host disease was similar, but there was more chronic graft-versus-host disease in the blood stem cell group [hazard ratio (HR)=1.29, P=0.02]. There were no significant differences in non-relapse mortality, relapse incidence and leukemia-free survival between the two groups among acute myeloid leukemia patients in remission. In patients with advanced leukemia, non-relapse mortality was lower (HR=0.61, P=0.02) and leukemia-free survival was prolonged (HR=0.67, P=0.002) when blood stem cells were used. At 3 years, leukemia-free survival for all patients, regardless of remission status, was 41% for both treatment groups. The outcome was not affected after multivariable analysis adjusted for confounders.Conclusion: Blood stem cells compared to bone marrow in matched unrelated donor transplantation for acute myeloid leukemia patients in remission resulted in the same rates of leukemia-free survival. In patients with advanced leukemia, the blood stem cell group had reduced non-relapse mortality and improved leukemia-free survival.© 2012 The Association for the Publication of the Journal of Internal Medicine
- Something’s happening here; what it is ain’t exactly ...
- Provitamin A carotenoids are independently associated wit... Background and aim: Carotenoids in plasma are inversely associated with cardiovascular risk. Low levels can be explained by low dietary intake but also by a number of other factors including inflammatory activity. Given that matrix metalloproteinase (MMP)-9 has an important role in inflammation and cardiovascular disease, we hypothesized that circulating MMP-9 levels would be inversely related to total or single carotenoids in a general population cohort.Methods: A well-characterized population-based cohort of 285 Swedish men and women (45–69 years) was used for the present study. The intake of carotenoid-rich fruits and vegetables was estimated from a food frequency questionnaire. Levels of MMP-9, C-reactive protein (CRP), interleukin (IL)-6 and six major carotenoids [β-cryptoxanthine, α-carotene, β-carotene, lutein (+ zeaxanthin) and lycopene] were determined in plasma.Results: Lower plasma levels of total and single carotenoids were associated with lower dietary intake of carotenoids, older age, male sex, lower physical activity, higher alcohol consumption, higher body mass index (BMI), higher systolic and diastolic blood pressures, lower levels of total cholesterol and HDL cholesterol and higher levels of CRP, IL-6 and MMP-9. After multivariate adjustments, plasma levels of total carotenoids and provitamin A carotenoids (β-cryptoxanthine, α-carotene and β-carotene) remained independently associated with sex, dietary intake of carotenoids, BMI, HDL cholesterol and MMP-9, while associations with CRP and IL-6 were not maintained. Neither dietary intake of carotenoid-rich fruits and vegetables, nor vitamin supplement use was associated with MMP-9, CRP or IL-6 levels.Conclusion: Plasma carotenoids were associated with a variety of factors including age, sex, dietary intake and metabolic variables. A new finding was the independent relationship in plasma between low provitamin A carotenoids and high MMP-9, suggesting a link between these carotenoids, matrix turnover and arterial remodelling.© 2012 The Association for the Publication of the Journal of Internal Medicine
Journal of General Internal Medicine (Online First™)
- The VALUE Framework: Training Residents to Provide Value-... Abstract National efforts to improve the value of health care must include graduate medical education (GME) if they are to succeed. Proposals to teach residents to provide value-based care have come from the Medicare Payment Advisory Commission (MedPAC), the Accreditation Council for Graduate Medical Education (ACGME) and the American College of Physicians (ACP). Such proposals skip a key step: residency programs currently lack a clear strategy to prepare residents to assess and deliver value-based care. In this article, we present the VALUE Framework for programs to utilize to teach residents to assess and deliver value-based care for their patients. We then present more than 20 opportunities for residency programs to incorporate training in value-based care. Content Type Journal ArticleCategory PerspectivesPages 1-5DOI 10.1007/s11606-012-2076-7Authors Mitesh S. Patel, Hospital of the University of Pennsylvania, 3400 Spruce St., 100 Centrex, Philadelphia, PA 19104, USAMatthew M. Davis, University of Michigan Medical School, Ann Arbor, MI, USAMonica L. Lypson, University of Michigan Medical School, Ann Arbor, MI, USA Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
- Two Poems by B.A. St. Andrews Two Poems by B.A. St. Andrews Content Type Journal ArticleCategory Healing Arts: Text and ContextPages 1-3DOI 10.1007/s11606-012-2080-yAuthors Clayton J. Baker, Division of Medical Humanities, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
- A Randomized Trial of Peer Coach and Office Staff Support... Abstract OBJECTIVE Adopting features of the Chronic Care Model may reduce coronary heart disease risk and blood pressure in vulnerable populations. We evaluated a peer and practice team intervention on reduction in 4-year coronary heart disease risk and systolic blood pressure. DESIGN AND SUBJECTS A single blind, randomized, controlled trial in two adjacent urban university-affiliated primary care practices. Two hundred eighty African-American subjects aged 40 to 75 with uncontrolled hypertension. INTERVENTION Three monthly calls from trained peer patients with well-controlled hypertension and, on alternate months, two practice staff visits to review a personalized 4-year heart disease risk calculator and slide shows about heart disease risks. All subjects received usual physician care and brochures about healthy cooking and heart disease. MAIN MEASURES Change in 4-year coronary heart disease risk (primary) and change in systolic blood pressure, both assessed at 6 months. KEY RESULTS At baseline, the 136 intervention and 144 control subjects’ mean 4-year coronary heart disease risk did not differ (intervention = 5.8 % and control = 6.4 %, P = 0.39), and their mean systolic blood pressure was the same (140.5 mmHg, p = 0.83). Endpoint data for coronary heart disease were obtained for 69 % of intervention and 82 % of control subjects. After multiple imputation for missing endpoint data, the reduction in risk among all 280 subjects favored the intervention, but was not statistically significant (difference −0.73 %, 95 % confidence interval: -1.54 % to 0.09 %, p = 0.08). Among the 247 subjects with a systolic blood pressure endpoint (85 % of intervention and 91 % of control subjects), more intervention than control subjects achieved a >5 mmHg reduction (61 % versus 45 %, respectively, p = 0.01). After multiple imputation, the absolute reduction in systolic blood pressure was also greater for the intervention group (difference −6.47 mmHg, 95 % confidence interval: −10.69 to −2.25, P = 0.003). One patient died in each study arm. CONCLUSIONS Peer patient and office-based behavioral support for African-American patients with uncontrolled hypertension did not result in a significantly greater reduction in coronary heart disease risk but did significantly reduce systolic blood pressure. Content Type Journal ArticleCategory Original ResearchPages 1-7DOI 10.1007/s11606-012-2095-4Authors Barbara J. Turner, ReACH Center and Department of Medicine and Department of Family and Community Medicine, University of Texas Health Science Center San Antonio and University Health System, 7410 John Smith Road, Suite 1050, San Antonio, TX 78229, USAChristopher S. Hollenbeak, Departments of Surgery and Public Health Sciences, Penn State College of Medicine, Hershey, PA 17033, USAYuanyuan Liang, ReACH Center and Department of Epidemiology and Biostatistics and Department of Urology, University of Texas Health Science Center, San Antonio, TX 78209, USAKavita Pandit, University of Pennsylvania Undergraduate Program, Philadelphia, PA 19104, USAShelly Joseph, University of Pennsylvania Undergraduate Program, Philadelphia, PA 19104, USAMark G. Weiner, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
- Spinal Epidural Abscess with Discitis and Vertebral Osteo... Spinal Epidural Abscess with Discitis and Vertebral Osteomyelitis Content Type Journal ArticleCategory Clinical Practice: Clinical ImagesPages 1-1DOI 10.1007/s11606-012-2066-9Authors Will Carpenter, VA Hospital, 4150 Clement St., San Francisco, CA 94121, USANima Afshar, VA Hospital, 4150 Clement St., San Francisco, CA 94121, USAKip Mihara, VA Hospital, 4150 Clement St., San Francisco, CA 94121, USA Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
- Usability of FDA-Approved Medication Guides Abstract BACKGROUND Medication guides are required documents to be distributed to patients in order to convey serious risks associated with certain prescribed medicines. Little is known about the effectiveness of this information to adequately inform patients on safe use. OBJECTIVE To examine the readability, suitability, and comprehensibility of medication guides, particularly for those with limited literacy. DESIGN Assessments of suitability and readability of 185 medication guides, and a sub-study examining change in suitability and readability from 2006 to 2010 among 32 of the medication guides (Study 1); ‘open book’ comprehension assessment of medication guides (Study 2). SETTING Two general internal medicine clinics in Chicago, IL. PATIENTS Four hundred and forty-nine adults seeking primary care services, ages 18–85. MEASUREMENTS For Study 1, the Suitability Assessment of Materials (SAM) and Lexile score for readability. For Study 2, a tailored comprehension assessment of content found in three representative medication guides. RESULTS The 185 analyzed medication guides were on average 1923 words (SD = 1022), with a mean reading level of 10–11th grade. Only one medication guide was deemed suitable in SAM analyses. None provided summaries or reviews, or framed the context first, while very few were rated as having made the purpose evident (8 %), or limited the scope of content (22 %). For Study 2, participants’ comprehension of medication guides was poor (M = 52.7 % correct responses, SD = 22.6). In multivariable analysis, low and marginal literacy were independently associated with poorer understanding (β = –14.3, 95 % CI –18.0 – –10.6, p < 0.001; low: β = –23.7, 95 % CI –28.3 – –19.0, p < 0.001). CONCLUSION Current medication guides are of little value to patients, as they are too complex and difficult to understand especially for individuals with limited literacy. Explicit guidance is offered for improving these print materials. Content Type Journal ArticleCategory Original ResearchPages 1-7DOI 10.1007/s11606-012-2068-7Authors Michael S. Wolf, Health Literacy and Learning Program, Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL 60611, USAJennifer King, Health Literacy and Learning Program, Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL 60611, USAElizabeth A. H. Wilson, Health Literacy and Learning Program, Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL 60611, USALaura M. Curtis, Health Literacy and Learning Program, Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL 60611, USAStacy Cooper Bailey, Health Literacy and Learning Program, Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL 60611, USAJames Duhig, Department of Pharmacy Administration, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USAAllison Russell, Health Literacy and Learning Program, Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL 60611, USAAshley Bergeron, Health Literacy and Learning Program, Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL 60611, USAAmanda Daly, Health Literacy and Learning Program, Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL 60611, USARuth M. Parker, Division of General Medicine, Emory University School of Medicine, Atlanta, GA, USATerry C. Davis, Department of Medicine-Pediatrics, Louisiana State University Health Sciences Center, Shreveport, LA, USAWilliam H. Shrank, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USABruce Lambert, Department of Pharmacy Administration, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
- “Learning by Doing”—Resident Perspectives on Develo... Abstract Background Reducing readmissions and post-discharge adverse events by improving the quality of discharge care has become a national priority, yet we have limited understanding about how physicians learn to provide high-quality discharge care. Methods We conducted in-depth, in-person interviews with housestaff physicians with qualitative analysis by a multi-disciplinary team using the constant comparative method to explore learning about high-quality discharge care as a systems-based practice and to identify opportunities to improve training around these concepts. Results We analyzed interview transcripts from 29 internal medicine residents: 17 (59 %) were interns (PGY-2 or PGY-3), 12 (41 %) seniors, and 17 (59 %) were female. We identified a recurrent theme of lack of formal training about the discharge process, substantial peer-to-peer instruction, and “learning by doing” on the wards. Within this theme, we identified five specific concepts related to systems-based practice and high-quality discharge care which residents learned during residency: (1) teamwork and the interdisciplinary nature of discharge planning; (2) advanced planning strategies to anticipate challenges in the discharge process; (3) patient safety and the concept of a “safe discharge;” (4) patient continuity of care and learning from post-discharge outcomes and; (5) documentation of discharge plans as a valuable skill. Conclusions Discharge care is an overlooked opportunity to teach concepts of systems-based practice explicitly as learning about discharge care is unstructured and individual experiences may vary considerably. Educational interventions to standardize learning about discharge care may improve the development of systems-based practice during residency and help improve the overall quality of discharge care at teaching hospitals. Content Type Journal ArticleCategory Original ResearchPages 1-7DOI 10.1007/s11606-012-2094-5Authors S. Ryan Greysen, Division of Hospital Medicine, University of California, San Francisco, 533 Parnassus Avenue, Box 0131, San Francisco, CA 94113, USADanise Schiliro, Department of Internal Medicine, New York University School of Medicine, New Haven, CT, USALeslie Curry, Department of Health Policy and Administration, Yale University School of Public Health, New Haven, CT, USAElizabeth H. Bradley, Department of Health Policy and Administration, Yale University School of Public Health, New Haven, CT, USALeora I. Horwitz, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
- Literacy, Cognitive Function, and Health: Results of the ... ABSTRACT BACKGROUND Emerging evidence suggests the relationship between health literacy and health outcomes could be explained by cognitive abilities. OBJECTIVE To investigate to what degree cognitive skills explain associations between health literacy, performance on common health tasks, and functional health status. DESIGN Two face-to-face, structured interviews spaced a week apart with three health literacy assessments and a comprehensive cognitive battery measuring ‘fluid’ abilities necessary to learn and apply new information, and ‘crystallized’ abilities such as background knowledge. SETTING An academic general internal medicine practice and three federally qualified health centers in Chicago, Illinois. PATIENTS Eight hundred and eighty-two English-speaking adults ages 55 to 74. MEASUREMENTS Health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine (REALM), Test of Functional Health Literacy in Adults (TOFHLA), and Newest Vital Sign (NVS). Performance on common health tasks were globally assessed and categorized as 1) comprehending print information, 2) recalling spoken information, 3) recalling multimedia information, 4) dosing and organizing medication, and 5) healthcare problem-solving. RESULTS Health literacy measures were strongly correlated with fluid and crystallized cognitive abilities (range: r = 0.57 to 0.77, all p < 0.001). Lower health literacy and weaker fluid and crystallized abilities were associated with poorer performance on healthcare tasks. In multivariable analyses, the association between health literacy and task performance was substantially reduced once fluid and crystallized cognitive abilities were entered into models (without cognitive abilities: β = −28.9, 95 % Confidence Interval (CI) -31.4 to −26.4, p; with cognitive abilities: β = −8.5, 95 % CI −10.9 to −6.0). LIMITATIONS Cross-sectional analyses, English-speaking, older adults only. CONCLUSIONS The most common measures used in health literacy studies are detecting individual differences in cognitive abilities, which may predict one’s capacity to engage in self-care and achieve desirable health outcomes. Future interventions should respond to all of the cognitive demands patients face in managing health, beyond reading and numeracy. Content Type Journal ArticleCategory Original ResearchPages 1-8DOI 10.1007/s11606-012-2079-4Authors Michael S. Wolf, Health Literacy and Learning Program, Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL 60611, USALaura M. Curtis, Health Literacy and Learning Program, Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL 60611, USAElizabeth A. H. Wilson, Health Literacy and Learning Program, Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL 60611, USAWilliam Revelle, Department of Psychology, Northwestern University, Evanston, IL, USAKatherine R. Waite, Health Literacy and Learning Program, Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL 60611, USASamuel G. Smith, Health Behaviour Research Centre, Department of Psychology, University College London, London, United KingdomSandra Weintraub, Department of Psychiatry & Behavioral Sciences, Feinberg School of Medicine at Northwestern University, Chicago, IL, USABeth Borosh, Department of Psychiatry & Behavioral Sciences, Feinberg School of Medicine at Northwestern University, Chicago, IL, USADavid N. Rapp, Department of Learning Sciences, School of Education and Social Policy, Northwestern University, Evanston, IL, USADenise C. Park, Center for Vital Longevity, University of Texas at Dallas, Dallas, USAIan C. Deary, Centre for Cognitive Ageing and Cognitive Epidemiology, Department of Psychology, University of Edinburgh, Edinburgh, United KingdomDavid W. Baker, Health Literacy and Learning Program, Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL 60611, USA Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
- Bending the Medicare Cost Curve for Physicians’ Service... Abstract In 1997 Congress created the Sustainable Growth Rate (SGR) formula for the payment of physicians under Part B of Medicare. SGR established a target rate of growth for aggregate costs of physician services under Part B, linked to growth in overall GDP. If growth in aggregate Part B costs exceeds the target, the rate at which physicians are paid in the following year is to be reduced by a corresponding amount. In SGR, Congress and the U.S. medical profession jointly confront a policy dilemma with no clear solution. For several years running, Congress has elected to postpone cuts in payment to physicians required under SGR. Absent further Congressional action, in 2013 physicians’ fees under Part B of Medicare will be reduced by more than 30 %. The historical roots of SGR suggest that a potential solution lies in shifting to regional expenditure targets—an approach applied successfully in Canada in the 1970s when Canadian Medicare confronted rising physician fees. The commission that created what was to become SGR was aware of the lessons learned in Canada, and recommended that they also be applied to U.S. Medicare. Content Type Journal ArticleCategory Health PolicyPages 1-5DOI 10.1007/s11606-012-2091-8Authors Donald A. Barr, Department of Pediatrics, Stanford University School of Medicine, c/o Program in Human Biology Building 20, Main Quad Stanford University, Stanford, CA 94305-2160, USA Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
- Vision and Persistence: Changing the Education of Physici... Vision and Persistence: Changing the Education of Physicians is Possible Content Type Journal ArticleCategory EditorialsPages 1-2DOI 10.1007/s11606-012-2078-5Authors Robert H. Brook, RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, USA Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
- End-of-Life Care from the Perspective of Primary Care Pro... ABSTRACT PURPOSE To explore the factors influencing primary care providers’ ability to care for their dying patients in Michigan. METHODS We conducted 16 focus groups to explore the provision of end-of-life care by 7 diverse primary care practices in southeast Michigan. Twenty-eight primary care providers and 22 clinical support staff participated in the study. Interviews were analyzed using thematic analysis. RESULTS Primary care providers (PCPs) wanted to care for their dying patients and felt largely competent to provide end-of-life care. They and their staff reported the presence of five structural factors that influenced their ability to do so: (1) continuity of care to help patients make treatment decisions and plan for the end of life; (2) scheduling flexibility and time with patients to address emergent needs, provide emotional support, and conduct meaningful end-of-life discussions; (3) information-sharing with outside providers and within the primary care practice; (4) coordination of care to address patients’ needs quickly; and (5) authority to act on behalf of their patients. CONCLUSIONS In order to provide end-of-life care, PCPs need structural supports within primary care for continuity of care, flexible scheduling, information-sharing, coordination of primary care, and protection of their authority. Content Type Journal ArticleCategory Original ResearchPages 1-7DOI 10.1007/s11606-012-2088-3Authors Maria J. Silveira, Veterans Administration, Health Services Research and Development Center of Excellence, 300 North Ingalls Building, Room 7C27, Box 5429, Ann Arbor, MI, USAJane Forman, Veterans Administration, Health Services Research and Development Center of Excellence, 300 North Ingalls Building, Room 7C27, Box 5429, Ann Arbor, MI, USA Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
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- New data highlight increases in hypertension, diabetes in... 16 May 2012 -- One in three adults worldwide has high blood pressure – a condition that causes around half of all deaths from stroke and heart disease, according to the World health statistics 2012 report released today. One in 10 adults has diabetes.
- WHO highlights importance of good hand hygiene for patien... 4 May 2012 – On Hand Hygiene Day (5 May), more than 15 000 health-care facilities from 156 countries are participating in the WHO Save Lives: Clean Your Hands Initiative by committing to improve patient safety by practicing better hand hygiene
- 15 Million babies born too soon 2 May 2012 -- Over one million of preterm babies die shortly after birth and countless others suffer some type of lifelong physical, neurological, or educational disability. An estimated 75% of preterm babies who die could survive without expensive care if a few proven and inexpensive treatments and preventions were available worldwide.
- World Malaria Day 2012 24 April 2012 -- On the eve of World Malaria Day 2012, WHO hails global progress in combating malaria but highlights the need to further reinforce the fight. WHO’s new initiative, T3: Test, Treat, Track, urges malaria-endemic countries and donors to move towards universal access to diagnostic testing and antimalarial treatment, and to build robust malaria surveillance systems.
- Global partners launch new plan to control and eliminate ... 24 April 2012 -- Announcing a new global strategy aimed at reducing measles deaths and congenital rubella syndrome to zero. The announcement comes with the publication of new data using a state-of-the-art methodology showing that efforts to reduce measles deaths have resulted in a 74% reduction in global measles deaths, from 2000 to 2010.
- World Immunization Week rolls out in more than 180 countries 23 April 2012 – The first World Immunization Week is being held from 21 to 28 April 2012 with activities in over 180 countries. The theme of the week, ‘Protect your world: Get vaccinated’, aims to reinforce the importance of immunization and encourage people everywhere to vaccinate themselves and their children against serious diseases.
- Dementia cases set to triple by 2050 but still largely ig... 11 April 2012 -- Worldwide, nearly 35.6 million people live with dementia which affects people in all countries. More than half (58%) live in low- and middle-income countries. A new WHO report, Dementia: a public health priority, recommends improving early diagnosis; raising public awareness about the disease and reducing stigma; and providing better care and more support to caregivers.
- New incentives needed to encourage health research and de... 5 April 2012 -- New sources of funding are needed to encourage health research specifically for diseases that affect people in developing countries.
- New protocol proposed to address illicit trade in tobacco... 4 March 2012 -- By agreeing to the protocol, governments have reiterated their commitment to tackling illicit trade in tobacco products.
- World Health Day 2012 - Good health adds life to years 03 April 2012 -- In the next few years, for the first time, there will be more people in the world aged over 60 than children aged less than five. On World Health Day (7 April), WHO is calling for urgent action to ensure that people reach old age in the best possible health.
All MayoClinic.com Topics
- Karo syrup for constipation: OK for babies? Karo syrup for constipation isn't likely to be effective for infants.
- Lead exposure: Tips to protect your child Lead exposure — Understand how to protect your child from exposure to lead.
- Low hemoglobin count Low hemoglobin count: Symptom — Overview covers possible causes of low hemoglobin levels in blood.
- Chronic kidney failure Chronic kidney failure — Comprehensive overview covers symptoms, causes of gradual loss of kidney function
- Prolactinoma: Options for treating pituitary gland tumor Prolactinoma — Comprehensive overview covers symptoms, causes, treatment of this pituitary gland tumor.
- Tongue-tie (ankyloglossia) Tongue-tie — Comprehensive overview covers symptoms and treatment options for an attached frenulum.
- Distraction opens the door to mistakes When you're driven to distraction and misplace your mobile phone, it's a hassle. But distraction can also lead to more serious and costly mistakes.
- Life's best lessons often emerge during caregiving role When mom gets Alzheimer's, it changes a child's role. And often life's greatest lessons can be learned as one grows into the role of caregiver.
- Brain tumor Brain tumor — Comprehensive overview covers signs, symptoms and treatments, including surgery.
- HPV test HPV test — Overview covers risks, results of this test for human papillomavirus (HPV) infection.
WebMD Health
- Study: Trash Old, Unused Drugs Prescription medication "take-back" programs are increasingly promoted as a way to safely dispose of unused drugs, but they are no better for the environment than simply throwing old drugs in the trash, a new study suggests.
- CDC: All Baby Boomers Should Get Tested for Hepatitis C One in 30 baby boomers may be infected with the hepatitis C virus, but few know it until it's too late for their livers.
- Athletes Better Equipped to Play Through the Pain New research confirms that athletes have a higher tolerance for pain than couch potatoes or even weekend warriors, and the finding could help investigators discover better ways to manage pain.
- FDA Approves Generic Versions of Plavix The FDA has approved several generic versions of the popular blood thinner Plavix (clopidogrel).
- Chinese Herb Kudzu May Help Drinkers Cut Down An extract from the Chinese herb kudzu may help drinkers cut down on drinking, according to a new, pilot study.
- Drowning Top Cause of Injury Deaths in Kids 1-4 Although the death rate for drowning in the U.S. has gone down in the last decade, drowning leads to more deaths among young children aged 1 to 4 than any other cause except birth defects, a new report from the CDC reveals.
- Cognitive Therapy for Depression Cognitive therapy for depression teaches people how to use a mental "toolkit" to challenge negative thoughts. Over the long term, this process can bring about positive changes in how a depressed person sees the world.
- More People -- Even Kids -- Need to Wear Sunglasses With summer nearly upon us, our sunglass habits could use improvement, according to a new report issued today by The Vision Council, an industry group.
- Fewer U.S. Teens and Young Adults Smoke Fewer American teens and young adults are smoking cigarettes, a new government report shows.
- For Some Athletes, Head Blows May Hamper Learning College football and hockey players sustain numerous blows to the head every season. Those hits, according to a new study, may add up to brain injuries that impact learning.
CNN.com - Health
- Searching for a medical miracle From the famous French village of Lourdes to spiritual healers, Amanda Enayati details the search for miracles in the face of illness.
- Is there a bias against creativity? Creativity has taken center stage in recent years, with a slew of books, articles and TED talks extolling the virtues of imagination and exhorting young and old to go out and exercise their creative muscle.
- Photos: 'Lucky 7' train in Hawaii The 2012 Fit Nation Tri Challenge Team is made up of seven CNN viewers selected to train for the Nautica Malibu Triathlon with Dr. Sanjay Gupta in September. For updates, visit the Fit Nation page, follow the team on Twitter, or like our page on Facebook.
- Choosing the right sunscreen Reporter Edgar Treiguts tells us what to look for and avoid when we're buying sunscreen.
- Tips for good dental health We all know that good oral care can lead to a lifetime of healthy teeth and gums. Reporter Joe Carter has some tips.
- Sippy cups, binkies could be dangerous A new study finds that sippy cups, binkies and bottles can injure children if they fall while using them.
- Challenges of college with autism Reporter Susan Hendricks looks at the challenges of going to college when you have autism spectrum disorder.
- Cancers caused by infections When we think of what causes cancer, what often comes to mind is tobacco smoke, having a family history of the disease.
- Nuts: Portion control is key Nuts pack a powerful punch as a snack, but portion control is key. Susan Hendricks has more in today's Health Minute.
- Mosquito season is back Mosquito season is back and West Nile is already showing up.
MedlinePlus Health News
- Lose Weight, Lose a Risk Source: HealthDay - Related MedlinePlus Pages: Cancer, Weight Control
- FDA Statement Regarding Azithromycin (Zithromax) and the ... Source: Food and Drug Administration Related MedlinePlus Page: Antibiotics
- Task Force Recommends Team-Based Care for Improving Blood... Source: Centers for Disease Control and Prevention Related MedlinePlus Page: High Blood Pressure
- Survey Reveals Growing National Impact of Asthma Source: Centers for Disease Control and Prevention Related MedlinePlus Page: Asthma
- Diabetes Can Take a Toll on Your Emotions And this psychological component may make it harder to control the blood-sugar disorder, experts say Source: HealthDay Related MedlinePlus Pages: Depression, Diabetes
- Sun Safety: Save Your Skin! Source: Food and Drug Administration - Related MedlinePlus Page: Sun Exposure
- Breastfed Babies May Gain Less Weight Babies who are fed milk from their mothers' breasts gain less weight over their first year compared to babies fed milk -- breast or formula -- from a bottle, suggests a new study.Source: Reuters Health Related MedlinePlus Pages: Breast Feeding, Infant and Newborn Development, Infant and Newborn Nutrition
- FDA Approves Generic Versions of Plavix Price of widely used blood thinner should drop for heart patients Source: HealthDay Related MedlinePlus Page: Blood Thinners
- Looking Away as You Get Needle Does Lower Pain, Study Shows 'See no needle' may be good advice, researchers say Source: HealthDay Related MedlinePlus Pages: Childhood Immunization, Immunization, Pain
- Fewer Girls Completing All Three HPV Shots Among girls and women who get their first human papillomavirus, or HPV, vaccine, the percent who complete all three doses is dropping, according to a new study.Source: Reuters Health Related MedlinePlus Pages: Childhood Immunization, HPV
Health Blog
- U.S. Suggests All Baby Boomers Should Get Tested for Hepa... U.S. health officials are proposing all baby boomers get tested for hepatitis C, because theyre five times more likely than other adults to have the potentially fatal liver virus and many might not know theyre at risk.
- A.M. Vitals: FDA OKs Generic Plavix Also: A CDC report says drowning is the No. 1 cause of injury death in children aged 1-4; researchers map the genetic code of 21 breast cancers; and food companies and consumer groups press for stalled food regulation.
- J&J Recall Watch: McNeil Recalls Imodium Lot Johnson & Johnson's McNeil Consumer Healthcare unit is recalling 53,892 packages, or one lot, of the diarrhea treatment Imodium from distributors after discovering some of the packages could have a slight tear or hole.
- Restaurant Claims Prompt Push for Standardized ‘Gluten-... The launch of "gluten-free" pizza that still should be avoided by people with full-blown celiac disease has prompted a physicians group to call for the standardization of the labeling of gluten-free foods.
- Why Expose a Child to the Risks of a Clinical Trial? One ... One mom explains how her family made the tough choice to enroll a daughter in a clinical trial of a cancer drug, and how it was the right thing to do.
- A.M. Vitals: U.S. Lowers Bar on Lead Poisoning Also: A study shows chain restaurants largely don't meet U.S. government nutritional guidelines; an antibiotic is linked with rare, but fatal, heart risk; and two paralyzed people moved a robot arm with their thoughts.
- Healthy Food Is a Better Deal Than Junk, USDA Says Healthy food isn't necessarily more expensive than junk food, according to a new government report.
- Study Suggests Coffee May Be Linked to Longer Life, But… Coffee drinkers are getting a bit more reassurance that their beverage of choice may not be bad for them, and might even be linked to living longer.
- A.M. Vitals: New Alzheimer’s Trial; Home HIV Test Here's what's making health news this morning: New Bid to Prevent Alzheimer's Early (WSJ): An Alzheimer's drug to be tested mostly on an extended family predisposed to the disease will mark the first large-scale trial of an experimental treatment on people who don't yet show signs of memory loss. Cardinal Health Settles With U.S. Over Pills (WSJ): The U.S. government on Tuesday settled with Cardinal Health over allegations the company distributed large quantities of addictive pain pills in Florida, backing away from a legal showdown over the pharmacy industry's responsibility for what officials call the country's deadliest drug problem.
- Sleep or Sex: Do You Have to Choose? Memory-foam mattresses are the fastest-growing category of mattresses, but for some buyers, there's a tradeoff....
National Institutes of Health (NIH) News Releases
- Optogenetics project takes top NIDA Addiction Science Award A project that maps dopamine circuits in the prefrontal cortex through optogenetic manipulation was given top honors in this year’s annual Addiction Science Awards at the 2012 Intel International Science and Engineering Fair (ISEF) -- the world's largest science competition for high school students. The awards were presented by the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health, and Friends of NIDA, a coalition that supports NIDA’s mission. The Intel ISEF Addiction Science Awards were presented at a ceremony Thursday night at the David L. Lawrence Convention Center in Pittsburgh.
- NIH-led study finds genetic test results do not trigger i... People have increasing opportunities to participate in genetic testing that can indicate their range of risk for developing a disease. Receiving these results does not appreciably drive up or diminish test recipients’ demand for potentially costly follow-up health services, according to a study performed by researchers at the National Institutes of Health and colleagues at other institutions.
- NIH study finds that coffee drinkers have lower risk of d... Older adults who drank coffee -- caffeinated or decaffeinated -- had a lower risk of death overall than others who did not drink coffee, according a study by researchers from the National Cancer Institute (NCI), part of the National Institutes of Health, and AARP.
- Paralyzed individuals use thought-controlled robotic arm ... In an ongoing clinical trial, a paralyzed woman was able to reach for and sip from a drink on her own -- for the first time in nearly 15 years -- by using her thoughts to direct a robotic arm. The trial, funded in part by the National Institutes of Health, is evaluating the safety and feasibility of an investigational device called the BrainGate neural interface system.
- NIH-funded research provides new clues on how ApoE4 affec... Common variants of the ApoE gene are strongly associated with the risk of developing late-onset Alzheimer's disease, but the gene's role in the disease has been unclear. Now, researchers funded by the National Institutes of Health have found that in mice, having the most risky variant of ApoE damages the blood vessels that feed the brain.
- NINR welcomes five new members to the National Advisory C... The National Institute of Nursing Research (NINR) announces five new members to the National Advisory Council for Nursing Research (NACNR), the institute's principal advisory board. Members of the council are drawn from the scientific and lay communities, embodying a diverse perspective from the fields of nursing, public and health policy, law, and economics. NINR, a component of the National Institutes of Health, is the primary federal agency for the support of nursing research.
- NIH statement on HIV Vaccine Awareness Day - May 18, 2012 There is a growing consensus that we can significantly curtail the HIV/AIDS pandemic by implementing scientifically proven HIV prevention strategies, such as voluntary medically supervised adult male circumcision, prevention of mother-to-child transmission and treatment as prevention.
AOL News
- Pink Glove Dance Reaching Millions A video showing hundreds of dancing hospital employees wearing pink gloves in support of breast cancer awareness has become an Internet sensation. The video, put together over two days with the help of 200 employees at a Portland, Oregon hospital, has more than 3 million hits and thousands of comments on YouTube.
- 10 Million Cans of Slim-Fast Recalled Unilever announces a massive recall of Slim-Fast diet drinks, citing concerns about the presence of Bacillus cereus, a bacteria that can cause diarrhea, nausea, and vomiting. The manufacturer is urging consumers to discard any cans of the beverage immediately and offering them a full refund.
- Magnetic Discs Could Kill Cancer Cells Doctors may have discovered an unlikely tool to kill cancer cells: tiny magnetic discs, too small to be seen by the naked eye. The discs are just 60 billionths of a meter thick, said the French press agency AFP. The so-called "nanodiscs" are made of an iron-nickel alloy, the agency reported. When they are subjected to a magnetic field, the discs vibrate. This movement damages the membranes of cancer cells and causes them to self-destruct.
- Mother's Instinct Saves Daughter When Andrea Samples' 15-year-old daughter, Jessica, got sick with the swine flu in late September, her instinct was to have a doctor check the girl -- three days in a row. Jessica ended up spending two weeks in intensive care after the virus hit her heart.
- Kangaroos May Hold Skin Cancer Cure How can scientists help humans avoid the scourge of skin cancer? One possible answer has now jumped out at an Australian research team: a DNA repair enzyme found in kangaroos. Although the enzyme does not make kangaroos immune to skin cancer, it gives them added protection from the sun's rays.
- Stifling Anger Tied to Heart Attacks Men who don't air their grievances over conflicts at work are more than twice as likely to have a heart attack as those who vent their anger.
- Doctors Treat ADHD with Marijuana In California, the state with the nation's most permissive medical marijuana law, some children with attention deficit hyperacitivty disorder, or ADHD, are being treated with marijuana -- a fact that has sparked a heated debate over the move. The state does not compile statistics on prescriptions for specific conditions, like ADHD. And many doctors and patients are reluctant to talk about it. Still, experts say such prescriptions are becoming more common as the number of pot dispensaries and doctors prescribing marijuana continues to grow. And not everyone is happy about it.
- Diabetic's Rare Condition Baffles Docs An 18-year-old Briton suffers from an extreme form of diabetes that causes her blood sugar to fluctuate wildly, the Daily Mail reports.
- Critics Blast Advice About Mammograms Reactions to new government guidelines for breast cancer screenings have been visceral and immediate, and have sparked instant disagreement among doctors. "We've been saving lives," said Dr. Constance Lehman, medical director of radiology and director of breast imaging at Seattle's Cancer Care Alliance, "and to have these trends reversed in a totally misguided effort to save money is just wrong."
- Study Links Folic Acid to Cancer Increase A study of heart patients in Norway finds that those who took folic acid and vitamin B12 supplements had slightly more of an increased risk for cancer than those who didn't take the supplements, according to Web MD Health News.
WashingtonPost Health News
- President’s Council on Fitness backs Wii, Kinect and ot... We called it “the devil’s machine” in my house, and the Faustian bargain we struck over that first Nintendo 64 would have impressed Lucifer himself. We bought it for my son when he was perhaps 7; it provided countless hours of contentment for him and an equal measure of downtime for Mom and Dad. Read full article >>
- The struggles of D.C. area yoga studios The deal with yoga in Washington is getting kind of complicated. If it’s a bargain you’re after, that’s not hard to find, especially with DC Yoga Week starting Sunday. Now in its seventh year, the event is eight days of free and $5 classes at 24 studios across the area. (This year, Maryland and Virginia studios are taking part, too.) And any other week, there’s a good chance folks can snag a Groupon or Living Social deal or similar discount on their downward-facing dogs. Read full article >>
- Spin/yoga classes find balance of body and mind It seems as though we are always struggling for balance in our lives. Work or play? Spend or save? Eat that doughnut or save those calories? The same is true for our fitness regimens. Everyone from the Centers for Disease Control and Prevention to your physician wants you to mix cardiovascular workouts with strength training, stretching and balance drills. How do you fit it all in? Read full article >>
- Alternative bachelorette parties: trapeze, ballet barre, ... The morning after 25-year-old Nicki Bonebrake’s bachelorette party two weeks ago, she could barely get out of bed. The problem wasn’t that the Gaithersburg resident had stayed out all night with her friends — although she had. It was that her body was still dealing with the fact that she’d spent the previous morning learning the art of flying trapeze. Read full article >>
- 5 so-called health foods you should avoid Eating healthy can be harder than you think, thanks to an enterprising food industry that wants us to consume more than we need. That’s because our country’s agricultural system produces twice what most people require, according to the U.S. Department of Agriculture’s Economic Research Service. This encourages creative marketing to unload the excess, much of it with minimal nutritional value. As a nutrition consultant, I know that words such as “low fat,” “high fiber,” “multigrain” and “natural” can fool even the most sophisticated customers into believing what they’re buying is healthful. So what can you do? First, make a habit of reading the ingredients list, not just the Nutrition Facts panel. And remember the following products worth resisting. Read full article >>
- Fairfax County wellness calendar, May 17-24 Parkinson’s exercise class Thursdays, 1:30-2:30 p.m. Greenbriar Community Center, 4615 Stringfellow Rd., Chantilly. 703-378-7221. $10; care partners, $5. Registration required. Breast-feeding support For mothers and babies. Thursdays, 10-11 a.m. Inova Fairfax Hospital (Women's Center, seventh floor), 3300 Gallows Rd., Falls Church. 703-776-6455. Free. Read full article >>
- D.C. wellness calendar, May 17-24 “Active Wellness at St. Alban’s” Seated yoga and other Iona Senior Services programs. Weekdays, 10 a.m.-2 p.m. St. Alban’s Episcopal Church, 3001 Wisconsin Ave. NW. 202-895-9448, Ext. 4. Donations welcome. Read full article >>
- Southern Maryland wellness calendar, May 17-24 “Eliminating Varicose Veins” A presentation by vascular surgeon James Salander. Thursday, 7-8 p.m. Calvert Memorial Hospital, 100 Hospital Rd., Prince Frederick. 410-535-8233. 410-535-4000. Memory loss and dementia workshop A presentation on “the basics” by the Alzheimer’s Association. Thursday, 10 a.m.-noon. College of Southern Maryland, 22950 Hollywood Rd., Leonardtown. www.alz.org/nca. 703-359-4440. 240-725-5499. ProgramNCA@alz.org. Read full article >>
- Featured Advertiser
- Prince William County wellness calendar, May 17 to 24, 2012 Al-Anon/Alateen groups A fellowship of relatives and friends of alcoholics. Visit www.alanonva.com for Thursday meeting times and locations. 703-534-4357. Free. Overeaters Anonymous “Meditation and Writing.” Thursdays at 7 a.m. St. Benedict Monastery, 9535 Linton Hall Rd., Bristow. 703-361-0106. www.oanova.org. Free. Read full article >>
American Medical News
- CMS eases rules to cut doctors’ regulatory burdens Changes to proposed regulations on Medicare conditions of participation will maintain self-governing medical staff requirements at hospitals and save nearly $1 billion.
- Teen immunization rates improve with middle school vaccin... Because no state requires all recommended immunizations, physicians are advised to educate adolescents and their families about them.
- GAO: Doctors should submit more data to get meaningful us... CMS is taking the recommendation into consideration as it prepares to conduct audits to see whether practices qualify for bonuses.
- Physicians receive federal innovation grants With support from the health system reform law, 26 projects aim to reduce health spending through decreased utilization and improved primary care access.
- EHR incentive payments improve bottom line of for-profit ... A debt-rating agency predicts they will use the extra money toward acquisitions.
- Obesity raises women’s risk of rheumatoid arthritis An estimated 1.5 million U.S. adults have the autoimmune disorder. Complications include heart problems, lung disease and osteoporosis.
- Health plans providing detailed cost estimates of doctor ... Patients could come to a physician’s office with down-to-the-penny prices and compare negotiated rates for multiple physicians and hospitals.
- Omega-3 intake linked to lower levels of protein associat... An estimated 5.4 million Americans, including 200,000 younger than 65, have the neurologic condition.
- Stage 2 meaningful use rules sharply criticized by physic... The American Medical Association and state and specialty societies call for less aggressive criteria in the Medicare and Medicaid electronic health record incentive program.
- Celebrities make pitch for patient safety panel An independent entity modeled after the National Transportation Safety Board could transform patient safety, proponents argue. Skeptics say the agency would be redundant.
FOXNews.com
- Should you go gluten-free? Perhaps you have been considered going gluten-free? Before you stop eating breads, pastas and cereals let’s look at the facts about gluten, Celiac, gluten intolerance and gluten sensitivity
- Pfizer recalls 650,000 bottles of Advil Liqui-Gels Pfizer Inc. has recalled more than 650,000 bottles of Advil pain-relief medicine due to the potential for a strong odor in the product
- CDC to baby boomers: Get tested for hepatitis C The Centers for Disease Control and Prevention on Friday released draft recommendations calling for all baby boomers to get a one-time blood test for the liver disease. That's everyone born from 1945 to 1965
- Many rare gene mutations may be associated with common di... Two large surveys of the human genome indicate that it may be much harder than scientists once thought to map out all the genetic mutations that underpin common human diseases, complicating the potential development of personalized, gene-based treatments
- Georgia woman battling flesh-eating bacteria will lose ha... Aimee Copeland, the 24-year-old Georgia graduate student fighting aggressive flesh-eating bacteria, was informed by her father Thursday that the doctors would have to amputate her hands and her remaining foot
- It's not just what you eat, but when you eat Weight gain may be caused in part by eating on an odd eating schedule, rather than only by eating too many calories, a new study in mice suggests
- Sex, age may affect athletes' concussion recovery Female and high school athletes may need more time to recover from a concussion than their male or college counterparts, a new study finds.
- Distracted mind may block pain signals Mental diversions have long been known to make pain easier to handle, and new research suggests that's more than just a psychological phenomenon
- First stem cell drug approved for systemic disease treatment Osiris Therapeutics Inc said on Thursday that Canadian health regulators have approved its treatment for acute graft-versus host disease in children, making it the first stem cell drug to be approved for a systemic disease anywhere in the world
- Texas sextuplets improving, 3 breathing on own A hospital official says three of the premature sextuplets born last month in Houston are now breathing on their own
CBC | Health News
- Hepatitis C blood tests suggested for baby boomers All baby boomers should get tested for hepatitis C, U.S. health officials recommend.
- Vitamin D non-skeletal health benefits unclear Taking vitamin D supplements for bone health is fine but using it to prevent and treat other diseases doesn't have clear evidence, a panel of medical experts says.
- Health groups urge Ottawa to save refugee services The heads of several of Canada's leading health-care organizations have written a strongly worded letter to the federal immigration minister, urging him to rescind plans to cut health services to refugees and refugee claimants.
- Ontario sets up panel to tackle childhood obesity The Ontario government is setting up an expert panel to tackle childhood obesity.
- Healthy foods can cost less Most fruits, vegetables and other healthy foods cost less than foods high in fat, sugar and salt, U.S. agriculture department study says.
- Misdiagnosis leads to lawsuit in woman's death The family of a woman who died of a heart attack shortly after she was sent home from a central Newfoundland emergency room has filed a civil lawsuit.
- Weight loss during pregnancy helps mom and baby Pregnant women who are overweight and obese can safely reduce their weight by eating a healthy diet to reduce the risks of complications for themselves and their baby.
- 'Good' cholesterol's heart benefits challenged Having naturally high levels of "good" cholesterol doesn't lower the risk of heart attacks as believed.
- Health unit wants healthy food supplement money The Windsor Essex County Health Unit board unanimously passed a motion to petition the premier to implement a monthly $100 healthy food supplement.
- What's the fuss about coffee? Why did coffee study make headlines?
The Globe and Mail - Health News
- Lightening blindness's burden With only a handful of doctors trained in low-vision rehabilitation, many Canadians go without advanced visuals aids that could lessen the burden of their disability
- Look out 'cause this stuff is TOXIC! Beware the rubber duck: According to a new book, our bodies are soaking in harmful chemicals that leach out of household items
- Plan for a good death - talk about your wishes We're not very good at dying
- Didgeridoo inspires sleep apnea workout Playing the Australian aboriginal wind instrument seems to help those affected
- Fishing: the cause of more drowning deaths While we revel in water's delights, we too rarely consider its dangers
- A DASH of prevention can protect your heart The diet, known for its ability to lower high blood pressure, may also cut in half your risk of heart failure
- Cheese puffs, with added vitamin D Canada inches closer to a decision on whether to allow companies to add vitamins and minerals to packaged or processed food
- Six steps urged to reverse RN shortfall Canada could have a shortfall of 60,000 registered nurses by the year 2022
- Pharma freebies sway med students Even trivial handouts influence the brand of drugs favoured by students, says new research paper
- Thousands of Canadians sign up for cancer study 31,000 volunteers have already been enlisted to participate in the Canadian Partnership Against Cancer's decades-long investigation
msnbc.com: Health
- Does organic food turn people into jerks? Renate Raymond has encountered her fair share of organic food snobs, but a recent trip to a Seattle market left her feeling like she'd stumbled onto the set of "Portlandia.
- Donna Summer like thousands of nonsmokers killed by lung ... Lung cancer’s sticky stigma as, primarily, a self-inflicted disease prompted Donna Summer’s publicist to release a terse statement Friday to emphasize the singer was “a non-smoker.
- Flesh-eating disease patient to lose hands, foot Faced with the prospect of losing both hands and her one remaining foot, a young Georgia woman battling to survive a case of flesh-eating bacteria that has already claimed one leg mouthed the words "Let's do this."
- Mad cow quarantines lifted at two U.S. dairies Officials have lifted quarantines on two Central California dairies linked to a case of mad cow disease, after investigators found the illness didn't come from cattle feed.
- Baby boomers need hep C test for liver, CDC says All baby boomers should be tested at least once for the liver-destroying hepatitis C virus, according to proposed guidelines from U.S. health officials released on Friday.
- Salmonella-linked sushi toll climbs to 316 The toll from latest outbreak of salmonella-spiked Sushi has climbed to 316, according to a new government report. And that number may be a huge underestimate, since food safety officials estimate that for every salmonella infection they hear about, 29.3 go unreported.
- For guys, meat is macho, veggies wimpy New research pinpoints why so many guys avoid vegetables yet lick their chops when they sniff marbled chunks of cow sizzling on the grill. In America and more than 20 Western nations, people see a metaphoric link between men and meat.
- Depressed people spend more time chatting online What if your smartphone were to tell you, “I think you need to see a mental health professional?
- Is healthy food really more expensive? Contrary to popular belief, it can actually cost more to eat badly. In fact, a new government report finds that nutritious foods – such as grains, vegetables, fruit and dairy – typically cost less than items high in saturated fat and added sugars.
- Being blind actually does heighten other senses We’ve all heard about the amazing ability of some blind people to hear, smell, or touch with such a high degree of acuity that they become almost savant-like.
WSJ.com: Health
- Red Tape Hobbles a Harvest of Life-Saving Rice Matt Ridlley on the lifesaving role of micronutrients and how a dispute over rice is depriving the poor.
- India's Drug Proposals Spark Debate India's government is facing stiff resistance from foreign and local pharmaceutical companies over its plan to severely limit prices for drugs.
- FDA Approves Generic Versions of Plavix The U.S. Food and Drug Administration on Thursday approved generic versions of blood-thinning drug Plavix.
- Human Genome Adopts Poison Pill Human Genome Sciences adopted a shareholder rights plan with a 15% trigger in the wake of Glaxo's $2.6 billion hostile takeover bid for the biotech firm.
- Drug Trial Boosts Hope for Tailored Treatment Pfizer's drug Xalkori for adult lung cancer is showing promise against childhood cancers, illustrating how personalized medicine is emerging as a weapon against pediatric malignancies.
- Stroke Victims Move Robot Arm With Thoughts Two paralyzed patients used their thoughts to steer a robotic arm and grasp physical objects, a notable advance in the quest to restore some function to people with limb paralysis.
- Bid to Coax States on Health Exchanges The Obama administration on Wednesday made a fresh bid to coax reluctant governors to work with the federal government to help enact the health-overhaul law.
- Zytiga Can Nix Some Prostate Tumors A study looking at small group of men with prostate cancer showed the use of Johnson & Johnson's Zytiga eliminated or greatly reduced the size of prostate tumors in one-third of patients treated for six months before surgery.
- Lead-Poisoning Threshold for Kids Revised U.S. health officials halved the minimum threshold for lead poisoning in children younger than 6.
- Federal Probe of Medtronic Ends A federal probe into Medtronic's marketing of a bone-graft product, Infuse, is over, the company said.
PLoS Medicine: New Articles
- Pregnancy and Infant Outcomes among HIV-Infected Women Ta... by Diana M. Gibb, Hilda Kizito, Elizabeth C. Russell, Ennie Chidziva, Eva Zalwango, Ruth Nalumenya, Moira Spyer, Dinah Tumukunde, Kusum Nathoo, Paula Munderi, Hope Kyomugisha, James Hakim, Heiner Grosskurth, Charles F. Gilks, A. Sarah Walker, Phillipa Musoke, on behalf of the DART trial team Background Few data have described long-term outcomes for infants born to HIV-infected African women taking antiretroviral therapy (ART) in pregnancy. This is particularly true for World Health Organization (WHO)–recommended tenofovir-containing first-line regimens, which are increasingly used and known to cause renal and bone toxicities; concerns have been raised about potential toxicity in babies due to in utero tenofovir exposure. Methods and Findings Pregnancy outcome and maternal/infant ART were collected in Ugandan/Zimbabwean HIV-infected women initiating ART during The Development of AntiRetroviral Therapy in Africa (DART) trial, which compared routine laboratory monitoring (CD4; toxicity) versus clinically driven monitoring. Women were followed 15 January 2003 to 28 September 2009. Infant feeding, clinical status, and biochemistry/haematology results were collected in a separate infant study. Effect of in utero ART exposure on infant growth was analysed using random effects models.382 pregnancies occurred in 302/1,867 (16%) women (4.4/100 woman-years [95% CI 4.0–4.9]). 226/390 (58%) outcomes were live-births, 27 (7%) stillbirths (≥22 wk), and 137 (35%) terminations/miscarriages (p>0.4). Of 219 surviving infants, 182 (83%) enrolled in the follow-up study; median (interquartile range [IQR]) age at last visit was 25 (12–38) months. From mothers' ART, 62/9/111 infants had no/20%–89%/≥90% in utero tenofovir exposure; most were also zidovudine/lamivudine exposed. All 172 infants tested were HIV-negative (ten untested). Only 73/182(40%) infants were breast-fed for median 94 (IQR 75–212) days. Overall, 14 infants died at median (IQR) age 9 (3–23) months, giving 5% 12-month mortality; six of 14 were HIV-uninfected; eight untested infants died of respiratory infection (three), sepsis (two), burns (one), measles (one), unknown (one). During follow-up, no bone fractures were reported to have occurred; 12/368 creatinines and seven out of 305 phosphates were grade one (16) or two (three) in 14 children with no effect of in utero tenofovir (p>0.1). There was no evidence that in utero tenofovir affected growth after 2 years (p = 0.38). Attained height- and weight for age were similar to general (HIV-uninfected) Ugandan populations. Study limitations included relatively small size and lack of randomisation to maternal ART regimens. Conclusions Overall 1-year 5% infant mortality was similar to the 2%–4% post-neonatal mortality observed in this region. No increase in congenital, renal, or growth abnormalities was observed with in utero tenofovir exposure. Although some infants died untested, absence of recorded HIV infection with combination ART in pregnancy is encouraging. Detailed safety of tenofovir for pre-exposure prophylaxis will need confirmation from longer term follow-up of larger numbers of exposed children. Trial registration www.controlled-trials.com ISRCTN13968779 Please see later in the article for the Editors' Summary
- Innovation and Access to Medicines for Neglected Populati... by Suerie Moon, Jorge Bermudez, Ellen 't Hoen
- A New Deal for Global Health R&D? The Recommendations of ... by John-Arne Røttingen, Claudia Chamas
- Six-Year Follow-Up of Impact of Co-proxamol Withdrawal in... by Keith Hawton, Helen Bergen, Sue Simkin, Claudia Wells, Navneet Kapur, David Gunnell Background The analgesic co-proxamol (paracetamol/dextropropoxyphene combination) has been widely involved in fatal poisoning. Concerns about its safety/effectiveness profile and widespread use for suicidal poisoning prompted its withdrawal in the UK in 2005, with partial withdrawal between 2005 and 2007, and full withdrawal in 2008. Our objective in this study was to assess the association between co-proxamol withdrawal and prescribing and deaths in England and Wales in 2005–2010 compared with 1998–2004, including estimation of possible substitution effects by other analgesics. Methods and Findings We obtained prescribing data from the NHS Health and Social Care Information Centre (England) and Prescribing Services Partneriaeth Cydwasanaethau GIG Cymru (Wales), and mortality data from the Office for National Statistics. We carried out an interrupted time-series analysis of prescribing and deaths (suicide, open verdicts, accidental poisonings) involving single analgesics. The reduction in prescribing of co-proxamol following its withdrawal in 2005 was accompanied by increases in prescribing of several other analgesics (co-codamol, paracetamol, codeine, co-dydramol, tramadol, oxycodone, and morphine) during 2005–2010 compared with 1998–2004. These changes were associated with major reductions in deaths due to poisoning with co-proxamol receiving verdicts of suicide and undetermined cause of −21 deaths (95% CI −34 to −8) per quarter, equating to approximately 500 fewer suicide deaths (−61%) over the 6 years 2005–2010, and −25 deaths (95% CI −38 to −12) per quarter, equating to 600 fewer deaths (−62%) when accidental poisoning deaths were included. There was little observed change in deaths involving other analgesics, apart from an increase in oxycodone poisonings, but numbers were small. Limitations were that the study was based on deaths involving single drugs alone and changes in deaths involving prescribed morphine could not be assessed. Conclusions During the 6 years following the withdrawal of co-proxamol in the UK, there was a major reduction in poisoning deaths involving this drug, without apparent significant increase in deaths involving other analgesics. Please see later in the article for the Editors' Summary
- Does Development Assistance for Health Really Displace Go... by Rajaie Batniji, Eran Bendavid
- Criminal Justice Reform as HIV and TB Prevention in Afric... by Katherine W. Todrys, Joseph J. Amon
- The Effect of Elevated Body Mass Index on Ischemic Heart ... by Børge G. Nordestgaard, Tom M. Palmer, Marianne Benn, Jeppe Zacho, Anne Tybjærg-Hansen, George Davey Smith, Nicholas J. Timpson Background Adiposity, assessed as elevated body mass index (BMI), is associated with increased risk of ischemic heart disease (IHD); however, whether this is causal is unknown. We tested the hypothesis that positive observational associations between BMI and IHD are causal. Methods and Findings In 75,627 individuals taken from two population-based and one case-control study in Copenhagen, we measured BMI, ascertained 11,056 IHD events, and genotyped FTO(rs9939609), MC4R(rs17782313), and TMEM18(rs6548238). Using genotypes as a combined allele score in instrumental variable analyses, the causal odds ratio (OR) between BMI and IHD was estimated and compared with observational estimates. The allele score-BMI and the allele score-IHD associations used to estimate the causal OR were also calculated individually. In observational analyses the OR for IHD was 1.26 (95% CI 1.19–1.34) for every 4 kg/m2 increase in BMI. A one-unit allele score increase associated with a 0.28 kg/m2 (95 CI% 0.20–0.36) increase in BMI and an OR for IHD of 1.03 (95% CI 1.01–1.05) (corresponding to an average 1.68 kg/m2 BMI increase and 18% increase in the odds of IHD for those carrying all six BMI increasing alleles). In instrumental variable analysis using the same allele score the causal IHD OR for a 4 kg/m2 increase in BMI was 1.52 (95% CI 1.12–2.05). Conclusions For every 4 kg/m2 increase in BMI, observational estimates suggested a 26% increase in odds for IHD while causal estimates suggested a 52% increase. These data add evidence to support a causal link between increased BMI and IHD risk, though the mechanism may ultimately be through intermediate factors like hypertension, dyslipidemia, and type 2 diabetes. This work has important policy implications for public health, given the continuous nature of the BMI-IHD association and the modifiable nature of BMI. This analysis demonstrates the value of observational studies and their ability to provide unbiased results through inclusion of genetic data avoiding confounding, reverse causation, and bias. Please see later in the article for the Editors' Summary
- The Midwives Service Scheme in Nigeria by Seye Abimbola, Ugo Okoli, Olalekan Olubajo, Mohammed J. Abdullahi, Muhammad A. Pate
- Induction of Labor versus Expectant Management in Women w... by David P. van der Ham, Sylvia M. C. Vijgen, Jan G. Nijhuis, Johannes J. van Beek, Brent C. Opmeer, Antonius L. M. Mulder, Rob Moonen, Mariët Groenewout, Mariëlle G. van Pampus, Gerald D. Mantel, Kitty W. M. Bloemenkamp, Wim J. van Wijngaarden, Marko Sikkema, Monique C. Haak, Paula J. M. Pernet, Martina Porath, Jan F. M. Molkenboer, Simone Kuppens, Anneke Kwee, Michael E. Kars, Mallory Woiski, Martin J. N. Weinans, Hajo I. J. Wildschut, Bettina M. C. Akerboom, Ben W. J. Mol, Christine Willekes, on behalf of the PPROMEXIL trial group Background At present, there is insufficient evidence to guide appropriate management of women with preterm prelabor rupture of membranes (PPROM) near term. Methods and Findings We conducted an open-label randomized controlled trial in 60 hospitals in The Netherlands, which included non-laboring women with >24 h of PPROM between 34+0 and 37+0 wk of gestation. Participants were randomly allocated in a 1∶1 ratio to induction of labor (IoL) or expectant management (EM) using block randomization. The main outcome was neonatal sepsis. Secondary outcomes included mode of delivery, respiratory distress syndrome (RDS), and chorioamnionitis. Patients and caregivers were not blinded to randomization status. We updated a prior meta-analysis on the effect of both interventions on neonatal sepsis, RDS, and cesarean section rate.From 1 January 2007 to 9 September 2009, 776 patients in 60 hospitals were eligible for the study, of which 536 patients were randomized. Four patients were excluded after randomization. We allocated 266 women (268 neonates) to IoL and 266 women (270 neonates) to EM. Neonatal sepsis occurred in seven (2.6%) newborns of women in the IoL group and in 11 (4.1%) neonates in the EM group (relative risk [RR] 0.64; 95% confidence interval [CI] 0.25 to 1.6). RDS was seen in 21 (7.8%, IoL) versus 17 neonates (6.3%, EM) (RR 1.3; 95% CI 0.67 to 2.3), and a cesarean section was performed in 36 (13%, IoL) versus 37 (14%, EM) women (RR 0.98; 95% CI 0.64 to 1.50). The risk for chorioamnionitis was reduced in the IoL group. No serious adverse events were reported.Updating an existing meta-analysis with our trial results (the only eligible trial for the update) indicated RRs of 1.06 (95% CI 0.64 to 1.76) for neonatal sepsis (eight trials, 1,230 neonates) and 1.27 (95% CI 0.98 to 1.65) for cesarean section (eight trials, 1,222 women) for IoL compared with EM. Conclusions In women whose pregnancy is complicated by late PPROM, neither our trial nor the updated meta-analysis indicates that IoL substantially improves pregnancy outcomes compared with EM. Trial registration Current Controlled Trials ISRCTN29313500 Please see later in the article for the Editors' Summary
- Does Conflict of Interest Disclosure Worsen Bias? by The PLoS Medicine Editors
Forbes.com: Health News
- Obamacare Activists Prep to be 'Either Celebratory or Agi... BuzzFeed has obtained a three-page memo from Health Care for America Now, an umbrella group run by labor unions and MoveOn.org. The memo details how the organization and other White House allies plan to adopt alternate messages, depending on whether or not the Affordable Care Act is upheld by the Supreme Court. "Note that many of these [resources] can be lined up now, without any additional information about the timing of the specifics of the decision," the activists write. It's a free country, of course. But the memo makes for strange reading.
- Medicare Advantage Reform: Detaching Pay from Performance Medicare Advantage (MA) is the "private option" within Medicare. Private health insurers are paid a fixed monthly fee to provide at least the same minimum health benefits to their enrollees as "traditional" fee-for-service (FFS) Medicare, but they also have the ability to offer coordinated care, disease management, phone consultations, and other services that have the ...
- Are House Republicans Caving in on Repealing Obamacare? D... Politico is reporting that House Republicans are preparing for the possibility that the Supreme Court upholds the law by drafting new legislation. "When the court rules, we'll be ready," House Speaker John Boehner (R., Ohio) told the House Republican Conference on Wednesday. But what's surprising about alleged GOP plans is that they involve preserving significant???and damaging???aspects of the Affordable Care Act, for what appear to be political reasons. I'm not convinced that the story is accurate.
- On Heels Of Record Health IT Funding, Castlight Health Re... Founded only four years ago, Castlight is fast establishing itself as the leader in a field rarely associated with health care: cost transparency. The , Calif.-based company offers employees of self-insured companies the ability to compare medical procedures based on price and quality, which vary widely within the same geographical area. Earlier this month, it ...
- Drug Companies Are Testing Health Technology Drug companies are dipping into health technology???or at least skimming the surface. is a new player at this week's 2.0 matchmaking conference which seeks to pair health technology start-ups with deep-pocketed partners. The pharma company, which is a sponsor, says it is "interested in companies pursuing innovation/opportunities related to the digital workflow of health care ...
- How Obamacare Tackled the Pitfalls of Employer-Sponsored ... Last weekend, I explained why the discriminatory tax treatment of employer-sponsored insurance is the original sin behind America's exceedingly expensive health-care system. I also described why reforming this tax break is politically difficult, because lots of industry stakeholders have an economic interest in the status quo. Today, I'll leave those political considerations aside, and engage the most credible policy critiques of ESI tax reform. The good news is that the authors of Obamacare's "Cadillac tax" did most of the legwork for us.
- How Employer-Sponsored Insurance Drives Up Health Costs A new study in Health Affairs is attracting attention for its depiction of how powerful hospitals are extracting "steep payment increases" from insurers. But what the study really tells us is how much the exceptional cost of American health insurance is caused by our system's original sin: the fact that, due to a quirk in the federal tax code, most of us don't buy insurance for ourselves, but instead have it bought on our behalf by our employers.
- Will Buying Health Insurance Across State Lines Reduce Co... During the debate over Obamacare, Republicans have consistently promoted an alternative approach that involved allowing individuals to purchase health insurance across state lines. Interstate insurance purchasing was the second item in the health care section of the GOP's 2010 "Pledge to America," right after tort reform. It's also a part of Mitt Romney's plan to replace Obamacare. It makes intuitive sense: after all, we can buy most other things across state lines; why not health insurance? Credible skeptics, however, say that health insurance is different, and that interstate insurance won't reduce costs. Let's explore their arguments.
- Is This Patient Privacy Crusader Doing More Harm Than Good? If the electronic health records industry has a nemesis, it's Deborah Peel, the founder of Patient Privacy Rights. At a time when doctors and hospitals are digitizing their paper medical records as mandated by the government, Peel, a psychiatrist, has been the most vocal agitator against loss of patient privacy. In Peel's world, malefic forces ...
- Massachusetts Institutes Health-Care Price Controls. Is A... Under Governor Deval Patrick, Massachusetts has tried a couple of methods for limiting the government's exposure to rising health-care costs. First, Patrick forced insurers to stop raising premiums, which led to a predictable train wreck, as insurers started hemorrhaging cash. When a state appeals board overturned Patrick's decree, he shifted gears, and began going after the prices charged by hospitals and doctors. On Friday, the Massachusetts House unveiled new legislation toward that end. And progressive health-care observers around the country are taking notes.
The Differential: Medscape Med Students Blogs
- The Differential Has Moved! New location: http://blogs.medscape.com/thedifferential Be sure to bookmark the new address!
- Practice Makes Perfect Jeff Wonoprabowo -- Earlier this quarter I had a pretty busy afternoon. And for a while it was stressful, too. It all started when a 51-year-old man came into the hospital complaining about shortness of breath. On the way in...
- What Is the Best Age to Start Med School? Anna Burkhead -- The average age of my first-year medical school class was 24.5. The oldest member of the class was 41, and the mythical youngster was but a raw 19 years old. The most common age was probably 22...
- Illegal or Inappropriate? Thomas Robey -- “How old are you?” “Are you married?” “Do you have kids?” Have you ever been asked any of these questions? Have you ever been asked by a potential employer? Would your response depend on the inquisitor? If...
- Starting All Over Again Ben Bryner -- I'm finally on the home stretch for interviews. Only a few more left. As I've mentioned, the thing I like most about interviews is the chance to talk to the leaders in surgery, meet residents, and imagine...
- Catching Winter Bugs Lucia Li -- “If we had no winter, spring would not be so pleasant.” Winter brings many things. Like Christmas, frost, and an excuse for hot chocolate. Mostly, though, it brings norovirus. In as little as one day, the hospital...
- How I Got Into Medicine Ben Bryner -- I’m still interviewing for residency, just trying to take it one trip at a time. Traveling and finding my way around new cities and unfamiliar hospital buildings is always a little stressful, and I won’t miss that...
- To Be, Or Not To Be (In Class) Jeff Wonoprabowo -- As a first year student I attended the majority of lectures. There were, after a while, a few professors whose lecture style I preferred not to listen to. And there were a couple of days when I...
- What Do I Want To Be When I Grow Up? Kendra Campbell -- I’ve recently been thinking a lot about what I would have done with my life had I not gone to medical school. So, I was inspired by Colin's post to make a short list of what I...
- Resolutions of a Fourth-Year Med Student Anna Burkhead -- It’s finally 2009! This is the year that fourth-year medical students across the USA (and final year students all over the world) have been anticipating and dreading for untold amounts of time. It’s the year we get...
CasesBlog - Medical and Health Blog
- Social media and medicine - Stanford University Grand Rounds Graham Walker is one of the first medical bloggers. He went on a hiatus during his emergency medicine (EM) residency, and has now found new inspiration to blog as an EM attending at Stanford University medical center. This is his talk on social media and medicine at Stanford University Grand Rounds: http://youtu.be/qtkggenLmlE Dr. Walker: This is my talk on the dissemination of medical information over time, how the internet and social networking are changing medicine, and how to use digital tools to be a better clinician at the bedside. Here is Graham's list of Digital Tools to Improve the Specialty: http://gmergency.tumblr.com/post/22727728700/stanford-grand-rounds-may-9-2012 Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
- Top articles in medicine in May 2012 Here are my suggestions for some of the top articles in medicine in May 2012 so far: Point-of-care genetic testing for personalisation of antiplatelet treatment is effective http://goo.gl/ZWLvz Patient empowerment - who empowers whom? Virtually all people are patients at some point in their lives http://goo.gl/4YKjq Doctors' love-hate relationship with EHRs http://goo.gl/wd74F Why U.S. spends more on healthcare than other developed countries: Higher prices, readily accessible technology, obesity http://goo.gl/cid6S Austerely law transforms Spain’s health system from universal access to one based on employment | BMJ http://goo.gl/36u4C Bevacizumab (Avastin) is as effective as ranibizumab (Lucentis) for wet AMD and could save NHS millions - NHS http://goo.gl/JJ8uV Having 'Type D' Personality - a distressed and pessimistic outlook on life - May Affect Your Health http://goo.gl/kFbpA New Cautions About Bisphosphonate Use - NYTimes http://goo.gl/PYiKy How to Create Your Own Website using Blogger - Step-by-Step Guide for Physicians http://goo.gl/tCd37 Truvada (Emtriva + Viread), first drug to prevent HIV infection in healthy people at high risk (MSM, partners of HIV+) http://goo.gl/e1MJM Can mobile phones give you brain cancer? The verdict's still on hold http://goo.gl/gI6Ta Drink Water to Improve Test Scores http://goo.gl/MNB6k and http://goo.gl/EO12p The articles were selected from my Twitter and Google Reader streams. Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
- What it's like to study medicine at Cambridge (video) What is "the favorite" for medical students in the UK at the moment? Going into General Practice (at minute 2:45 of the video). They are also "very keen into going into a specialty such as pediatrics". This is a night and day difference compared to their counterparts in the U.S. From Cambridge University YouTube channel: "At Cambridge, we offer two medicine courses - the Standard Course and the Graduate Course. With both, our aim is to educate students to become compassionate, thoughtful, skilled members - and leaders - of the medical profession. Success in medicine requires application and hard work, both while studying and when in practice. However, it brings great rewards in terms of job satisfaction, involving as it does a combination of science and human interactions, and numerous career opportunities." To find out more about Medicine at Cambridge, see http://study.cam.ac.uk/undergraduate/courses/medicine Comments from Twitter: Nick Bennett @peds_id_doc: Best medical school in the world. Seriously. Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
- Best of Medical Blogs - weekly review and blog carnival The “Best of Medical Blogs - BMB weekly review and blog carnival” is a weekly summary of the best posts from medical blogs. Feel free to send your suggestions to my email at clinicalcases@gmail.com. Best of Medical Blogs (BMB) is published every Tuesday, just like the old Grand Rounds. A Medical Educator Joins Social Media: One Year Later Dr. Djuricich, Program Director in Medicine-Pediatrics at the Indiana University, shares what he has learned in one short year: If physicians and other health care professionals are not becoming involved in social media, they are missing out on a “place” where many of the patients already are. There is a lot of misinformation floating around on the internet. It is a duty of physicians to combat this and provide correct information. Do not let social media take over your life. The important things (family, friends, etc.) are still the important things, so don’t lose the priorities. http://goo.gl/zNfpe What explains blogging longevity? It's easy: blog for yourself, and share with others Dr. Centor explains his blogging longevity after 10-years of blogging. I've been blogging for 8 years, and I agreee with him: Why you should write a blog for yourself rather than for a shifting audience http://goo.gl/P8xtz Here's Dr. Centor again: Explaining longevity is subjective. Mostly, I like blogging. Basically I blog with myself in mind, and am gratified that others find my comments interesting. Blogging is never a chore. One cannot last 10 years doing a chore. http://goo.gl/Jyl2o Cardiologist Dr. Wes nominates the hardest to read Abstract of the Year at 2012 Heart Rhythm Society What is the abstract that contributes the smallest amount to our field while demonstrating the worst grammar, the most bureaucratic lingo and, of course, verbosity. The sentence that clinched it? "Conclusions: The harmonization of endpoint definitions, terminology, and clinical trial design paradigms provides consistency across clinical trial studies that can facility (sic) clinician acceptance of results and the evaluation of safety and effectiveness of devices and medicines for atrial fibrillation." http://goo.gl/ZstA0 Harvard Medical School Q&A blog doctor reflects on his readers’ feedback Dr. Komaroff from the blog Ask Doctor K.: “Since I began this column last September, I’ve received a lot of mail — both emails and “snail mail.” Mostly it’s been health questions. I can’t answer them all, but I try to answer as many as I can. However, I’ve also received complaints. Sometimes they represent an honest difference of perspective. On occasion, they reflect the fact that I’m a man.” http://goo.gl/XK3O1 A complete list of all academic medical journals available for the iPad The omnipresent blog iMedicalApps makes a good use of Google Docs spreadsheet to list the apps of many academic medical journals available for the iPad. I still have personal preference for the open web rather than apps but that’s just me. http://goo.gl/13Gjz What is postinfectious cough and how to treat it? From Dr. Matthew Mintz' blog: While the cause of the postinfectious cough is not known, it has been thought to be due to the extensive damage of cells lining the lung and widespread airway inflammation of the upper and/or lower airways. The good news is that this usually goes away by itself, the bad news is that it can take weeks or even months, and can be quite disruptive to patients lives. Since symptoms are caused primarily by inflammation and hyperresponsiveness/bronchoconstriction in the lungs (which is what we see in asthma), then treatment is likely best with something that treats both inflammation and bronchoconstriction in the lungs, such as an inhaled corticosteroid/long-acting beta agonist like Advair (which is commonly used in asthma). Use of Advair for postinfectious cough may be the single most common off-label use of any prescription product. Since inflammation can persist for weeks, it is important that Advair be used for at least 4 weeks. If symptoms return, the patient should be brought back for pulmonary function testing as this may be a new presentation of asthma. http://goo.gl/RgxLb Reality Social Media: Live Tweeting Brain Surgery. What is the downside of this marketing push? Dr. Wes explains: http://goo.gl/XbKwv "Healthcare Going To The Dogs" - a video for training hospital administrators http://goo.gl/hv40a and http://goo.gl/xsW4J Science blogging and self-promotion? http://goo.gl/yGUqS Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
- Depression affects up to 9% of U.S. population - how to d... From American Family Physician: Depression affects up to 9% of U.S. population. The U.S. Preventive Services Task Force recommends screening in adolescents and adults but it does not recommend screening for depression in children 7-11 years of age, or screening for suicide risk in the general population. The Patient Health Questionnaire (PHQ)-2 and PHQ-9 are commonly used and validated screening tools. The PHQ-2 has a 97% sensitivity and 67% specificity in adults. The PHQ-2 inquires about the frequency of depressed mood and anhedonia over the past 2 weeks, scoring each as 0 ("not at all") to 3 ("nearly every day"). PHQ-9 has a 61% sensitivity and 94% specificity in adults. The PHQ-9 depression module scores each of the 9 DSM-IV criteria as “0” (not at all) to “3” (nearly every day). If the PHQ-2 is positive for depression, the PHQ-9 should be administered. In older adults, the 15-item Geriatric Depression Scale is an appropriate follow-up test. If these screening tests are positive for depression, further evaluation is needed to confirm that the patient's symptoms meet the Diagnostic and Statistical Manual of Mental Disorders' (DSM) criteria for diagnosis. References: Screening for depression. Maurer DM. Am Fam Physician. 2012 Jan 15;85(2):139-44.Image source: Vincent van Gogh's 1890 painting At Eternity's Gate. Wikipedia, public domain. Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
- Top articles in medicine in May 2012 Here are my suggestions for some of the top articles in medicine in May 2012 so far: Is Geriatric Medicine Terminally Ill? asks Annals of Internal Medicine http://goo.gl/J4jMU Low vitamin D (below 50 nmol/L (20 ng/mL) increases risk for clinical disease among older adults http://goo.gl/tBXS4 Senior physicians keep working, putting off the R-word - 20% of U.S. physicians are older than 65 http://goo.gl/Dxgip Many young doctors worried about future of medicine - amednews http://goo.gl/r61lW "One of the greatest risks of social media is ignoring social media" says chief integrity officer of Cleveland Clinic. Patients want to use social media tools to manage health care http://goo.gl/9SAry Doctors can risk lawsuits when writing about patients - amednews points to books about patients as examples http://goo.gl/QhqFS Coffee is the most complex food known to man. It has 1200 flavor components. The nearest comparison is red wine with 450 chemical compounds in the flavor make-up. In most commercial blends there are 10 to 12 different coffees, from different farms. http://goo.gl/m2LwD Guidelines for social media use by Federation of State Medical Boards (FSMB) describe in detail what NOT to do: http://goo.gl/Raq2e Prevention of acute knee injuries in adolescent female football (soccer) players: warm-up could help http://goo.gl/dBgSS Is It Possible To Walk And Work At The Same Time? Kaiser Permanente tries walking meetings http://goo.gl/cRu8l Corneal transplantation - 2012 state of the art review in The Lancet http://goo.gl/JBAag Towards an optimum strategy in rheumatoid arthritis: For RA patients who fail initial methotrexate treatment, add-on disease-modifying antirheumatic drugs are appropriate http://goo.gl/ONq6u Time Spent Behind the Wheel May Increase Heart Health Risks, linked to less time spent exercising http://goo.gl/NUYX7 Recipe For Safer Drinking Water (from bacteria)? Add Sun, Salt And Lime http://goo.gl/kU2ZK The articles were selected from my Twitter and Google Reader streams. Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
- Healthcare social media - top articles Here are my suggestions for some of the top articles related to healthcare social media in the past 2 weeks: Healthcare social media is a moral obligation Healthcare social media is a 'moral obligation', says Farris Timimi, M.D., medical director for the Mayo Clinic Center for Social Media. Social media needs to be grown and nurtured for patients. "Our patients are there. Our moral obligation is to meet them where they're at and give them the information they need so they can seek recovery," Timimi said. "You've got to be ready for it. You build it for the patients; not for yourself. "This is not marketing," he added. "This is the right thing to do." http://goo.gl/BHzKf The New World Of Medical Tweeting 300 million users generate 300 million messages every day, and doctor are part of it. 38% of tweets are conversational - transferring information and spreading content. Twitter can be a strong educational tool. The American Medical Association has released a public statement about professionalism in social media: “Participating in social networking and other similar internet opportunities can support physicians’ personal expression, enable individual physicians to have a professional presence online, foster collegiality and camaraderie within the profession, provide opportunity to widely disseminate public health messages and other health communication." http://goo.gl/K2QtK Guidelines for social media use by Federation of State Medical Boards (FSMB) describe in detail what NOT to do: http://goo.gl/Raq2e Digital Strategies for Healthcare Organisations http://goo.gl/PZtWl Use of Social Media by Western European Hospitals: Longitudinal Study shows that SoMe awareness is growing http://goo.gl/l41tz Doctors can risk lawsuits when writing about patients - amednews points to books about patients as examples http://goo.gl/QhqFS GruntDoc: It’s my 10th Blogging Anniversary http://goo.gl/TkBc7 - Congratulations! A great reflection on a long journey. The articles were selected from my Twitter and Google Reader streams. Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
- Dermatology Art Contest by Mayo Clinic shows that art can... A Mayo Clinic dermatology art contest shows beauty really is skin deep. From Mayo Clinic News blog: A hair follicle or skin specimen that doesn’t look like much of anything to the naked eye can become a complex, colorful work of art under a microscope. The winner of the Mayo dermatologists’ first art contest in 2011 was “Hair Follicle Triplet”. Alexander Meves, M.D., used fluorescent dyes to highlight proteins. The inaugural winners of the art contest appeared in the May issue of the Journal of Cutaneous Pathology. “Every single day, dermatopathologists get to see beautiful images under the microscope, and most people never have the opportunity to see that. So I thought it would be a nice way to show not only the science of dermatopathology, but also the art,” says the contest’s creator, Dr. Lehman, a Mayo Clinic dermatopathologist. Dr. Lehman hopes medical societies will run with the idea and hold similar competitions to highlight aesthetics in their specialties. People in other lines of work can also celebrate the beauty of what they do each day, she says. Editor's note: Allergists should do something similar. We already highlight beautiful pollen allergens on the monthly covers of the ACAAI journal. “Art can be seen in every aspect of life,” Dr. Lehman says. “You just have to have an open mind and be looking for it.” References Dermatology Art Shows Beauty Really Is Skin Deep. Mayo Clinic News. Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
- Diary-Writing Has Psychological Benefits - Journal of Hap... Writing has long been used as a coping strategy and has been applied to improve psychological well-being. One study found that suicidal poets used more first-person singular pronouns (I, me, my) than the control group of poets. This study from Taiwan, published in the Journal of Happiness Studies, investigated the psychological displacement paradigm in diary-writing (PDPD) and its supposed psychological benefits. Study participants were randomly assigned to write about their recent negative life experiences two times a week for 2 weeks in PDPD group (diary-writing), or comparison group (no diary-writing). The diary-writing group (PDPD) showed a decrease in negative emotion and an increase in positive emotion immediately after each writing session (short term effect). They also had an increase in psychological well-being for at least 2 weeks (long term effect). References: The Psychological Displacement Paradigm in Diary-Writing (PDPD) and its Psychological Benefits. Jen-Ho Chang, Chin-Lan Huang and Yi-Cheng Lin. JOURNAL OF HAPPINESS STUDIES 2012, DOI: 10.1007/s10902-012-9321-y Comments from Google Plus and Twitter: Lin W: I guess blog writing might have the same effect? Ves Dimov, M.D.: It depends on the type of blogging you do, but yes, blogging can be a positive experience too. Dr. Amal Hasan @DrFloona: Diary-Writing Has Psychological Benefits bit.ly/wwMDmr” Until someone else reads it Dean Giustini @giustini: Diary-Writing Has Psychological Benefits bit.ly/wwMDmr [Isn't this why we blog Ves?] @DrVes: Well, I'm not sure. I don't blog about "negative experiences". Blog = archive for me Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
- Best of Medical Blogs - weekly review, blog carnival The “Best of Medical Blogs - weekly review, blog carnival” is a weekly summary of the best posts from medical blogs. Feel free to send your suggestions to my email at clinicalcases@gmail.com. Best of Medical Blogs is published every Tuesday, just like the old Grand Rounds. Social Networks for Doctors: Are We There, Yet? Twitter can be as inane, or as useful, as the accounts you follow. Sure, doctors use Facebook like everyone else, but – by and large – they haven’t tapped into the educational potential that online social networks offer. Once viewed as a trivial hobby by more eminent researchers and writers, blogs now serve as the elder statesmen of social media - and they can act as a base of operations for social networking. An excellent summary by Shiv Gaglani & Nicholas Genes: http://goo.gl/9DVbI A Twitter Primer for Physicians (aka Twitter 101 for Docs) Here are Dr. Ryan Madanick's suggestions: http://goo.gl/gNS5d. Dr. Madanick is a gastroenterologist at the University of North Carolina School of Medicine, as well as the Program Director for the GI & Hepatology Fellowship Program. 1. Consider starting with a private account. 2. Start following some accounts: Specialty societies and journals, let Twitter suggest some accounts, search for accounts with similar interests. 3. Listen to what others are saying. 4. Decide what to tweet. 5. Find a hashtag. The incredible frailty of life Realizing the incredible frailty of life and the battle to avoid irrational exuberance: a journey into the NICU as a Med-Peds uncle. This is a heartfelt article by Dr. Moises Auron from Cleveland Clinic: http://goo.gl/KvUbN The NYTimes gets it wrong on ECG screening of young athletes Dr. John Mandrola, a cardiac electrophysiologist, comments on a NYTimes article that included numerous inaccuracies and failed to tell important facts about the complexities of widespread screening of athletes. http://goo.gl/siEEp How one patient uses Social Media "Personally.. I don’t want to be a patient.. It’s totally the last thing I want to be…Before my diagnosis I shamefully has no idea what Rheumatoid arthritis (RA) was or what the consequences were of having a Chronic Illness. Patients and Doctors will find a solution together." A guest post at Dr. Ronan Kavanagh's blog. Dr. Kavanagh is rheumatologist from Ireland: http://goo.gl/daRfd Krokodil is a devastating homemade opiate Krokodil (or crocodile) refers to homemade batches of the opiate desomorphine (currently available without a prescription in Russia), and ingredients such as gasoline, paint thinner, hydrochloric acid, iodine, and red phosphorous. When injected, this highly impure mixture often causes skin to turn greenish grey and scaly, which may explain the drug’s name. Another explanation is that subsequent ischemia, gangrene and amputation has the same effect as a crocodile biting off a victim’s limb. From The Poison Review: http://goo.gl/VAq28 How to straighten a guidewire with one hand The Australian blog Life in the Fast Lane is one of the best blogs focused on emergency medicine. Here is one of their shorter posts: How to straighten a guidewire with one hand http://goo.gl/mC9zY GruntDoc: It’s my 10th Blogging Anniversary http://goo.gl/TkBc7 - Congratulations! A great reflection on a long journey. 10 Bad Assumptions Patients Make - a post by Dr. Rob http://goo.gl/EpmUO All papers at PLoS Medicine now reflect the public Twitter debate | Medical Museion http://goo.gl/Xmu5Y Caffeine and Sleep In Kids: It is a good rule of thumb to avoid soda entirely | Craig Canapari, MD http://goo.gl/W5HGS Using fruit to improving anaphylaxis care - use your expired injectable epinephrine on an orange, an allergists suggest http://goo.gl/AQIxw Are we too concerned with confidentiality? Former BMJ editor provides a personal example: http://goo.gl/0J3dp Comments from Twitter: John Mandrola, MD @drjohnm: Thx 4 shout out. Wow, lots of other great posts. Mike Cadogan @sandnsurf: Concise, pithy and diverse - great read Craig Canapari @DrCanapari: Honored to be included Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
Medgadget
- Hygieia’s DIGS Automatic Insulin Titration Device Shows... An experimental new device called Diabetes Insulin Guidance System (DIGS) from Hygieia, Inc. (Ann Arbor, MI) is being developed to automate insulin dosage titration in patients with type I and type II diabetes, based on measurements of blood glucose and analysis of patterns in the obtained data. The company hopes one day to provide patients with an automatically calculated insulin dosage adjustments between doctor visits, in hopes of improving their glycemic control.The company’s clinical advisory board is packed with diabetes experts such as Martin Abrahamson, MD from Joslin Diabetes Center in Boston, so they obviously know what they are doing. And the latest data seems to confirm that. A recent publication in Diabetes Technology and Therapeutics is quite positive for the technology, as it demonstrated DIGS’ potential to improve blood glucose control for insulin-using patients with type 2 or type 1 diabetes. Over the 12-week intervention period of the study, investigators observed:Read More
- UCSD Electronic Wireless Tattoo Receives Grant from the G... Last week, the Bill and Melinda Gates Foundation announced its latest round of grant winners for its Grand Challenges Explorations initiative. Among the recipients is a team from the University of California, San Diego and University of Illinois at Urbana-Champaign that is developing a tiny, flexible fetal monitor. We wrote about the technology behind the device back in August and were able to hear from David Icke, CEO of MC10, the company helping to commercialize it, at both FutureMed in February and at last month’s TEDMED conference.Described as an electronic “tattoo”, the device is a wearable patch of circuits, sensors, and wireless transmitters that sticks to the skin like a temporary tattoo and is able to stretch and flex with the skin. The researchers hope that the final product will continuously measure and monitor uterine contractions, fetal heart rate and oxygen, and maternal heart rate and body temperature.Read More
- NIH Director Francis Collins on Speeding Up Arrival of Ne... Francis Collins, Director of the National Institutes of Health, spoke at the last TEDMED about the challenges of converting fundamental research into practical therapeutics. In addition to proposing new approaches like repurposing of drugs and using manufactured human tissue for testing new compounds, he spoke on stage with a 15-year-old boy with Hutchinson–Gilford Progeria, a rare condition that accelerates aging, who had some words for medical researchers everywhere.Read More
- Medgadget Interviews Eric Berdinis and Jeff Kiske, Creato... Over the years we have been fortunate to cover numerous student designed medical devices and we are always amazed by the innovation and creativity demonstrated by these teams. In November of last year we covered one such project, the Kinecthesia, a haptic belt which allows the wearer to virtually sense objects ahead, and to the left and right thanks to three motors which vibrate in response to objects in their immediate vicinity. As the name would imply, at the heart of the Kinecthesia is an XBox Kinect 3D camera which is connected to a Beagle Board computing platform that processes the depth data from the device and drives the motors.Its two student creators, Eric Berdinis and Jeff Kisk, developed the Kinecthesia at Weiss Tech House, a student-run hub of technological innovation at the University of Pennsylvania that supports students in the creation, development and commercialization of innovative technologies. The project is very innovative and reflects a growing trend in hardware hacking and customization which is creeping into a number of fields including health technology.Read More
- Five Questions for Dr. Paul Walker of Spectral Diagnostics Sepsis is a huge problem, costing billions of dollars and hundreds of thousands of lives a year in the US alone. A Toronto, Canada-based startup Spectral Diagnostics Inc. is developing a promising technology to decrease morbidity and mortality of patients with sepsis. The company’s proprietary technology is integrated into Toraymyxin, a hemoperfusion adsorption column which is highly effective in removing circulating endotoxin from the bloodstream. Furthermore, Spectral Diagnostics has also developed the Endotoxin Activity Assay (EAA) – the only FDA cleared, CE marked rapid diagnostic for endotoxemia. According to a company representative, in 2009 interim results of a Phase II study were published in JAMA demonstrating that “Toraymyxin, when added to conventional therapy, significantly reduced 28-day mortality in patients with severe sepsis and septic shock, compared to patients only receiving conventional therapy. Due to these positive results, that trial was terminated early and a Phase III pivotal multicenter study has been launched in the U.S. and Canada.” To find out more about this technology and its future, we had a chance to conduct an interview with Dr. Paul Walker, President and CEO of Spectral Diagnostics.Dr. Jan Sinnige, Medgadget: Spectral Diagnostics recently started a phase three randomized controlled trial on Polymyxin B Hemoperfusion. What are the expectations according to the phase two results?Read More
- FlexLeg Gives Users With Lower-Leg Injuries Increased Mob... Ask anyone who’s ever had to spend part of their life hobbling around on crutches, and they’ll probably agree that it’s a chore. Running, let alone anything faster than a brisk walk, is out of the picture, and ascending or descending stairs becomes an adventure.A new product, called FlexLeg, from a couple of mechanical engineers from Brigham Young University in Utah, seeks to make life with an injured lower leg a little less burdensome. Looking somewhat like the Cheetah Flex-Foot prostheses that Olympic sprinter Oscar Pistorius uses, FlexLeg is a hands-free alternative for people with temporary lower-leg injuries to help them walk with a more natural rhythm than using crutches, and for those always on the go, the ability to even run.Read More
- F Cubed’s Pathogen Detector Will Make Swimming Holes Sa... During our recent tour of Northeast Indiana, we had the opportunity to visit F Cubed (F3), a startup supported by the Innovation Park at Notre Dame. F3 is developing a portable device that allows for rapid detection of DNA of harmful pathogens in under 30 minutes.We’ve written about a number of similar lab-on-chip detectors, but what sets the F3 system apart is its biochip technology. F3′s biochip, which is smaller than the size of a thumbnail, allows for the detection of multiple pathogens without the use of expensive and complicated optical devices. According to F3,Read More
- Using Colonoscopy to Predict Parkinson’s Disease? Roughly 60,000 people in the United States are diagnosed with Parkinson’s disease each year, according to the Parkinson’s Disease Foundation. In all, more than 1.5 million people in the United States suffer from the condition. Yet thousands of cases go undetected and diagnosing the disease in the early stages remains challenging.Early diagnosis of Parkinson’s enables the disease to be treated with drugs such as dopamine agonists and monoamine oxidase type-B inhibitors, which can alleviate the condition’s symptoms and postpone the need to begin levodopa therapy. Nevertheless, early diagnosis of Parkinson’s has remained challenging and misdiagnoses are common.Read More
- Severely Disabled People Control Robotic Arm Through Thou... We’ve been covering the development of the BrainGate brain-computer interface system for the last seven years, and we’re glad to see that it’s now at a point where severely disabled tetraplegics are able to control a robotic arm in three dimensional space purely by thinking about it.The system relies on a 96-channel microelectrode array that records the motor cortex neurons responsible for arm movement. Because the implant reads the very neurons that are normally activated during arm movement, the people in the study didn’t require any explicit training or instruction in operating the roboarm. One of the two people in the study, who last moved her arms effectively before a severe stroke 14 years prior, was able to control the robotic hand to pick up a cup and take a drink from it. See yourself in this Nature video:Read More
- Device Manufacturing 101: Orthopedic Implants and Instrum... We’re constantly giving you the scoop on the latest in orthopedic devices from our clinical and design perspective, but have you ever wondered about the steps that go into manufacturing these devices? There’s a lot of work in the process that turns an idea into an actual physical product, and often times it’s something we don’t think about.During our recent trip to Northeast Indiana, we had the opportunity to visit a number of manufacturing sites and learn the high-tech processes and technology that go into producing orthopedic implants and instruments. Here’s how it works!Read More
The Health Care Blog
- No Magic Pill to Cure Poor Medication Adherence By JESSIE GRUMAN You are sick with something-or-other and your doctor writes you a prescription for a medication. She briefly tells you what it’s for and how to take it. You go to the pharmacy, pick up the medication, go home and follow the instructions, right? I mean, how hard could it be? Pretty hard, it appears. [...]
- It’s THCB’s Health Wonk Review By Matthew Holt It’s Thursday morning. Fresh off the digital presses. It’s finally here. THCB (after a long absence) is back hosting Health Wonk Review…. Health IT Dept We start close to home with huge news for THCB’s sister organization Health 2.0. (FD-Matthew Holt THCB’s Founder is also Co-Chairman at Health 2.0). And the news is that the world [...]
- HIT Trends Summary for May 2011 By MICHAEL LAKE This is a summary of the HIT Trends report for May 2011. You can get the current issue or subscribe here. E-prescribing scale and innovation. Surescripts reports dramatic growth for e-prescribing with a third of office-based physicians on its network and 20% of all scripts now going electronically to pharmacies and mail order. Yet [...]
- Online Communities & Attrition from Health Intervention P... By GLENN LAFFEL, MD Provider-centric, face-to-face health intervention programs that help people quit smoking, lose weight and increase activity levels have been shown to work, but they are expensive, don’t scale, and inconvenient. By contrast, Internet-based programs with similar goals can be disseminated widely and inexpensively, and can be accessed by [...]
- Health 2.0 will be running challenges & scanning innovati... By Indu Subaiya & Matthew Holt We’re delighted to tell the Health 2.0 Community that all of your great work in the Health 2.0 Developer Challenge has received tremendous backing of the highest order. Today HHS confirmed officially that ONC is getting into the challenges business, and–working with our partner Capital Consulting Corporation–Health 2.0 will be [...]
- The Great Wellness Revolt of 2011 By MICHAEL TURPIN The scene opens with a fit, thirty-something man running down the hallway of an office building. His white shirt is stained on right side by what appears to be orange juice. He frantically looks behind him to see if anyone is following him and knocks over a female colleague – [...]
- The Unbridgeable Gap between Left and Right on Health Reform By JEFF GOLDSMITH Though thoroughly smothered under 2900 pages of well meaning but poorly focused, expert-driven “good works”, the core of the Affordable Care Act was providing 30 million people subsidized health insurance coverage. As the country continues to decide how it feels about this monumental legislation, a major ideological divide persists over whether the aggressive [...]
- Defining Quality in the Health Insurance Industry By VIPAN NIKORE, MD My patient, whom I’ll call Jane, had a neurologic disorder that prevented her from emptying her bladder properly. She required a permanent urinary foley catheter to help her urinate. Jane landed back at the hospital with yet another urinary tract infection – her third in one month. She had pus draining from [...]
- The Doctor is In (and Using an iPad) By JANE SARASOHN-KAHN The past year has seen a huge jump in the number of hours that physicians spend online; at the margin, the increase is due to physicians’ use of online via mobile platforms. Meredith Abreu-Ressi, President of Manhattan Research, shared her insights into the firm’s study, Taking the Pulse (v. 11), with me [...]
- All the Care that Money Will Buy By JOHN GOODMAN I believe we could spend our entire national income on health care. Not by frittering money away, but by spending it on goods and services that even in small ways could improve the odds of better health. (Examples below.) I find that most people in health policy agree with that assessment, but rarely do [...]
KevinMD.com
- The user interface for EHRs should be uniform The first thing I noticed when I walked into the physician’s office were the tall cabinets filled with manila folders, tabbed with names and organized alphabetically. There were three of these cabinets, taking up the entire length of the back wall, filled with hundreds upon hundreds of patients’ records. “I see you still have paper [...]
- Medical school and residency aren’t places for human gr... The end of my residency and beginning of my practice was the most wrenching experience of my life. I was woefully prepared for the transition. Full disclaimer: I was trained many years ago when residencies were acknowledged brutal demeaning processes. Things have changed considerably, but the psychological passage I endured still holds. Read the rest [...]
- How death can be a beautiful experience I was honored to be part of a beautiful experience in late January of 2011. It was the death of my mother-in-law at the direction of Trinity Hospice in Aiken, SC. Having never thought I would describe death as beautiful the word choice comes as a surprise even to me, a Sagittarius and straight shooter, [...]
- Keep the care in the health care I believe the greatest challenge in medicine today is keeping the “care” in healthcare. One of the most frustrating aspects of practicing medicine for me had to do with how difficult it had become to incorporate caring into my practice. I am not necessarily talking about the kind of caring associated with having a long-term, [...]
- Top stories in health and medicine this morning, May 18, ... This series is brought to you by MedPage Today. 1. Distractions Help Cut Pain. Distracting the mind not only can take the focus off pain but can actually dampen the body’s early physiological response to pain signals by way of endogenous opioids. 2. VA Uses More ‘Last-Resort’ Antibiotics. The use of “last resort” antibiotics by [...]
- Can pit crews really heal medicine? In his recent TED talk, Atul Gawande harkens back to the central thesis of his recent book The Checklist Manifesto: How to Get Things Right that medicine has become too complex for physicians to act as cowboys and instead should adopt the paradigm of a pit crew, utilizing teamwork and the humble checklist to solve problems and [...]
- Hospitals around the world aim to remain relevant to pati... “It was the best of times, it was the worst of times …” So begins a story called A Tale of Two Cities by Charles Dickens. Its about the differing responses of two different nations to the revolutionary events and social upheaval of 1775. I’m going to tell a tale of three hospitals. You’ll see [...]
- Help your radiologist out and provide as much history as ... The art of practicing medicine is in realizing that there is an overlap between normal variants and pathology. Being able to tell the difference can be difficult, but this where the art comes in. However, as physicians we must realize that sometimes this can not be differentiated. Radiology is no different. Many clinicians and non-health [...]
- 9 skin signs for a yearly visit to the dermatologist Visiting your dermatologist every year may be an important step to staying skin cancer-free. So, how do you know if you should schedule that annual appointment? The answer depends on how likely you are to get skin cancer. Do you fall into one of these groups? Then, it’s time for a skin check-up. Read the rest [...]
- Top stories in health and medicine this morning, May 17, ... This series is brought to you by MedPage Today. 1. Team Care Lowers ESRD Costs. A pilot program focused on collaborative care may improve outcomes and reduce costs associated with end-stage renal disease (ESRD). 2. Self-Management Program Flops for COPD. A clinical trial of self-management in patients with chronic obstructive pulmonary disease was stopped early [...]
Canadian Medicine
- Pesticide punch Wading through the produce aislesIf you think apples don’t taste like they used to, you’re probably right. The Environmental Working Group (http://www.ewg.org/foodnews/) has just updated its list showing pesticide levels in 53 types of produce, and apples – formally No. 4 of their “Dirty Dozen” – now weigh in at No. 1! Researchers at Purdue University in Lafayette, IN, analyzed 51,000 pesticide residue tests done over 10 years (2000-2009) by the U.S. Department of Agriculture and the Federal Food and Drug Administration. 98% of the apples tested contained pesticides out of over 700 samples. And most of the fruit and veggies under scrutiny had been washed and peeled, in order to represent more realistic eating conditions.Others that made the Dirty Dozen were celery, strawberries and peaches – which contained 57 different chemicals – along with greens such as kale, lettuce and hot peppers – treated with as many as 97 pesticides.If we stick to Canada’s Food Guide we’d consume a minimum of five servings of Mother Nature’s bounty every day. By choosing these from the least contaminated foods we’d ingest less than 2 pesticides. However, picking them from the Dirty Dozen would up our daily pesticide intake to 14 different chemicals – some of which are associated with nervous system disorders, chronic problems including cancer, endocrine system dysfunction, and lower intelligence levels in kids – who may (along with those in the fetal stage) be the most vulnerable to the synthetic residues.There’s also evidence that the phosphorus-rich fertilizers used in fields have contributed to the toxic blue-green algae blooms in our freshwater lakes, reported to cause vision loss and difficulty walking in some people who’ve been in contact with it, but that’s another story. When organic produce isn’t readily available -- at the market, or due to budgetary constraints – these lists could be your best shopping companions.Milena Katz
- UBC hospice gets rubber stamp Hospice residents are the winnersIt’s been five months since the UBC put their plan to build a hospice on the Point Grey Campus on hold. After checking out 15 locations, the Board of Governors agreed yesterday to stick with the plan, despite objections raised by the mostly new-immigrant Asian community living in the high-rise condo facing the sight. They say their opposition to the 15-bed facility has nothing to do with fears that property values might decrease or the "idea" of a hospice but rather deeply held cultural convictions based on their conceptions around death. According to Professor of Chinese Religions Paul Crowe, Chinese believe “on the assumption the world as we understand it is a unified, single place that’s inhabited by both the living and the spirits of the deceased; and there’s this deeply held concern that we need to keep the spirits of the deceased separate from the living.”Residents of the luxury tower say the prospect of having the hospice as neighbour has already triggered sickness and stress for them and their families.UBC delved deeper into possible concerns and did further study on the potential impact on traffic and property values. They concluded that the hospice development be ratified with additional conditions. They recommended that UBC plant trees between the two facilities, maintain outreach programs for new immigrants, and “identify other housing opportunities on campus for residents of the adjacent building who wish to move.” Also, UBC’s VP Stephen Owen stated, “An open-air courtyard in the hospice will be open-air but screened so that it is not visible to the outside.”The $15 million hospice would be used as a place for research and education, along with providing hospice care, a sorely lacking service for dying Canadians.Milena Katz
- End of the line for the gravy train? Pharma giant AstraZeneca will no longer fund doctors' travel to medical congresses, becoming the first leading drugmaker to renounce this common perk.Announcing the step at an industry conference in Istanbul, CEO David Brennan said that pharma "is a force for good. But if we're honest with ourselves ... we’re often seen as the bad guys." He cited a recent Harris poll in the U.S., which found that only 11% of Americans rated big pharma as trustworthy, when even banks had scored 20%. The same poll also found, though he didn't mention it, that pharma, along with oil, was the industry Americans most wanted to regulate more strictly.His company had resolved to address the problem by "never doing anything that could be misinterpreted," said Mr Brennan. "We have decided that we will no longer pay for doctors to attend international scientific and medical congresses but will instead focus our educational efforts on local educational opportunities for healthcare professionals." He added an interesting take on the doctor/pharm rep relationship from the other side of the fence: "I know from my own experience as a sales representative, you will encounter people who will ask for gifts, or other inducements. And they will threaten to take their business elsewhere, if you don’t acquiesce ... we have made it clear that our sales force have to say no."It's likely that other pharma companies will follow AstraZeneca's lead. The industry acted in a fairly coordinated manner in abandoning free gits like mugs and mousepads in recent years. And the announcement carries extra significance because Brennan, the only leading pharm CEO to come from a background in sales rather than medicine or chemistry, is also president of the the International Federation of Pharmaceutical Manufacturers and Associations. The drug industry has come under pressure recently over dealings abroad, particularly with employees of foreign public health services, including doctors. AstraZeneca and other British companies have had to contend with a new bribery act in the UK, while in the United States has been investigating big pharma under the Foreign Corrupt Practices Act (FCPA). Johnson & Johnson paid $78 million last month to settle British and American charges that it paid kickbacks to win business overseas. AstraZeneca itself is being investigated under FCPA for its dealings in China. Get Canadian Medicine news by email or in an RSS reader
- Army of psychopaths to spring up in 2013 If you thought grim things were forecast for 2012, just wait till 2013. An army of psychopaths will spring up overnight. Many of our friends and neighbours will suddenly develop alcohol problems. In fact, eminent psychiatrists fear that millions of us will slip over that ephemeral frontier that separates the normal from (to use the proper medical term) the Crazy.That's because 2013 will see the fifth coming of the brain-doctor's bible, the Book that tells us who is normal and who has a "disorder" - the Diagnostic and Statistical Manual of Mental Disorders. Is that weird neighbour just a jerk or does he have a syndrome? DSM-5 will decide.Maybe he's a psychopath. Because, after 33 years' absence, the honest psychopath makes his comeback in DSM-5. In DSMs III and IV, psychopaths were hidden under the euphemistic category of Antisocial Personality Disorder. But the latest draft of DSM-5 will brand these undesirables as Antisocial/Psychopathic Type, which has a fine condemnatory ring. In fact it sounds more like a judgement than a diagnosis. You can presumably cure a disorder, but can you cure a "type"? If anyone thinks this is all just semantics, consider the impact in recent years of three disorders that were redefined by DSM-IV in 1994: attention deficit disorder, autism, and child bipolar disorder. The Chairman of the DSM-IV task force, psychiatrist Allen Frances, now says his panel "inadvertently contributed to three false 'epidemics'.""I learned from painful experience how small changes in the definition of mental disorders can create huge, unintended consequences," wrote Dr Frances. "Clearly, our net was cast too wide and captured many 'patients' who might have been far better off never entering the mental health system."DSM-5 offers the opportunity to undo some mistakes in DSM-IV. The autistic spectrum was a bit of a dog's breakfast, and the next iteration will try to bring it some order, doing away in the process with Asperger's Syndrome and the unpopular diagnosis Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS). It seems a little harsh on Dr Asperger, whose name is being de-immortalized, but fair enough. But many more new diagnoses are trying to creep in, some pushed by eager researchers, others befriended by lawyers, all surely welcomed by big pharma. Each seeks to push the boundary between Normal and Crazy so that more people will fall into the second category. The draft includes a Hoarding Disorder. The proposed Mixed Anxiety Depression will capture millions who don't qualify for Major Depression but who constitute what we call 'the worrying type'. Irritable people who throw tantrums will have Disruptive Mood Dysregulation Disorder. There's Minor Neurocognitive Disorder for those with expected cognitive decline of ageing that's too mild to justify a diagnosis of Mild Neurocognitive Disorder .There's also constant pressure to ease the criteria for existing conditions. A study in Australia finds that the prevalence of alcohol use disorders is 62% higher under DSM-5 criteria than under DSM-IV. Adult ADD is also getting more broadly defined. It's the medicalization of normal, if bad, behaviour that scares Dr Frances and many other critics. Book needs appendectomyTo be fair, most of the worst ideas come from outside the American Psychiatric Association committees responsible for the drafts. Some of the silliest have already been rejected. Divorce lawyers will not get their "parental alienation syndrome", which would have allowed them to counter child abuse allegations by alleging that Mommy had turned Johnny against Daddy.Disorders that have made it this far in the process, however, are so far advanced that to ignore them would apparently be rude, so those that don't get a disease code are likely to end up in the Appendix on Axes for Further Study, which is beginning to sound like a smorgasbord of half-baked ideas, about as useful as a human appendix. One pseudo-condition that's already definitely heading there is Hypersexual Disorder, which has been derided as a philanderer's charter.The behavioural "addictions" - shopping addiction, computer game addiction, internet addiction, will also be relegated to the appendix, except for compulsive gambling, which became officially crazy in 1994 with DSM-IV. It makes the leap from humble Impulse Disorder to become the first recognized Behavioural Addiction. Can the others be far behind?One new condition that teeters between recognition and the obscurity of the appendix is Attenuated Psychosis Syndrome, a diagnosis intended to catch mostly young people who might be at risk of developing a real psychotic episode later in life, but who have never met any criteria for one. Those diagnosed, including the many false positives, would be treated with atypical antipsychotics, costly drugs with a heavy burden of side effects. The creators of DSM-5 declare themselves torn on this one, and welcome outside comment. In fact the whole process is in an open comment period until June 15. You can have your say here. OD Get Canadian Medicine news by email or in an RSS reader
- Not out of the woods yet Last year, Canada saw the biggest increase in new physicians in 20 years. About 2,700 extra practitioners brought the national total to around 68,000, according to figures released by CIHI, the Canadian Institute for Health Information.Most of the new physicians, about 2,300, were graduates of Canadian medical schools. A few more doctors returned to Canada than went abroad in 2009, perhaps partly due to the weakening of the US dollar. And about 300 new doctors were international medical graduates. Until about 2004, the number of physicians was barely keeping pace with the rising population. From 2004 to 2008, the rate of increase in physicians was double that of the general population. The 2009 increase was three times faster than the rate of increase of the population. Clearly, steps are being taken to address Canada’s chronic physician shortage. But a crunch is still coming, and this may not be enough to divert it. For the first time in decades, the average age of physicians didn’t increase in 2009. But it didn’t decrease either, hovering at 49.7 years. Is there any other job on earth where the average age is 50? Maybe being a nun. Meanwhile, the population ages apace. Older patients mean greater need, older doctors mean less provision. This is not to suggest that older doctors work less. On the contrary, many do longer hours than their younger colleagues. And many are delaying retirement. Quite a few may have been burned in the stock market collapse, and the 2009 figures may partly reflect their decision to work a few more years to replenish the retirement fund. Others aren’t retiring simply because they can’t find a replacement to take on their patients. Of physicians aged 70-79 in 2004, most were still working in 2008, a feat of endurance surely unmatched in any other profession. But retirement must come eventually. And with an average professional age of 50, the numbers leaving are going to be significant. At the same time, their young replacements appear to be working shorter hours. Doctors today want a life as well as a career. And the dramatic increase in female doctors means more family responsibilities – women doctors average about 8 hours less work per week. They have also proved more likely, in the past, to drop the profession altogether. Of the new class of 2009, 52% of general practitioners and 45% of specialists were women. (Ratios of women to men, strangely, vary quite sharply from one province to another. In Quebec, for example, the numbers are almost even, while in Manitoba male doctors outnumber female by 2-to-1.) Family practice continues to get short-changed, though the picture is improving. In 2004, just 23% of medical students said they wanted to go into family practice. In 2009, that had jumped to 33%. But it needs to be 40% to meet the actual need.And why is the need growing faster than the population? Because, of course, of the ageing of Canada. In 1921, one Canadian in 20 was aged over 65. Today, it’s one in eight. In 2026, it will hit one in five. And the “oldest old”, the 85-plus, is the fastest-growing group of all. Consumption of healthcare is astronomically higher in these age brackets. We’re not out of the woods yet.Owen Dyer
- Avandia gets its death certificate For three years now, the once-promising diabetes medication rosiglitazone (Avandia) has been waiting for the axe to fall. Sales plummeted after a 2007 meta-analysis in the New England Journal of Medicine linked the drug to a sharply increased risk of heart attack. Since then, further studies and observational data from Medicare have only confirmed that rosiglitazone increases heart attack risk in diabetic patients by 30 to 80%. Equally damning was data showing that this is not a class effect common to the thiazolidinediones – in fact rosiglitazone’s direct competitor pioglitazone has a fairly good cardiovascular risk profile. Many diabetologists have suggested that rosiglitazone remains a useful option in reducing glycemia, so long as it’s used with care, and only in patients without heart problems. But pioglitazone’s better showing really kicks the last leg out from under this argument. Rosiglitazone delivers nothing that pioglitazone doesn’t, except for extra cardiovascular risk.Rosiglitazone has had a Health Canada warning in its monongraph since 2007, issued a few weeks after the FDA gave it one of their notorious “black box” warnings. Its indications for use were also tightened considerably. Since then, sales have fallen by about two-thirds. The end has been drawing near, and this time, Health Canada beat the FDA to the punch. From now on, the drug will only be prescribed in Canada if patients sign a consent form acknowledging that they’re aware of added dangers of heart attack, angina and heart failure, plus unspecified “other risks”. The patient must also certify their awareness that “there are other options to treat my diabetes.”The physician, meanwhile, is enjoined not to use rosiglitazone-containing products except in cases when “all other oral antidiabetic agents, in monotherapy or in combination, do not result in adequate glycemic control or are inappropriate due to contraindications or intolerance.”So farewell, then, Avandia. Neither patient nor physician is likely to go along with that, especially when there’s a boatload of promising new diabetes drugs hitting the market. Drugs whose hidden pitfalls, if any, have yet to be revealed.What lesson may be gleaned from all of this? One reason rosiglitazone’s dangers went unnoticed for so long is that, while the drug brought much more cardiovascular risk than placebo, the effect was less noticeable when compared to other antihyperglycemic drugs like sulfonylureas and even the reliable standby metformin – because all of these drugs also increase the risk of lethal heart problems. It may seem odd that, when cardiovascular disease is the thing most likely to kill diabetic patients, we routinely treat diabetes with drugs that increase the risk of cardiovascular disease. It seems even odder when we consider that there’s a safe, cost-free way to reduce blood sugar that actually improves cardiovascular health … that is, exercising and eating a healthy diet of low glycemic index foods. Oddest of all, surely, is the fact that so many patients are apparently more comfortable with the idea of popping multiple pills with potentially grim side effects than they are with the idea of eating a few more vegetables and a bit less ice cream.Owen Dyer Get Canadian Medicine news by email or in an RSS reader
- A little bit of poison? Expert witnesses fail to acquit BPA in the court of public opinionLast month, Canada became the first – and still the only – country to formally declare bisphenol A (BPA) a toxin, listing the organic compound as hazardous both to human health and to the environment.BPA is an endocrine disruptor that can mimic the effects of estrogen. In vivo studies have linked even very low concentrations with permanent changes to the brains and reproductive systems of laboratory animals.Two years ago, Canada announced its intention to ban BPA from baby bottles, as did several US states. In the event, they were largely pre-empted by the industry, as the shower of negative publicity surrounding BPA made it commercially nonviable. But BPA hardly went away. In fact, it’s ubiquitous. It may be found in cellphone casings, cash register receipts, and all sorts of packaging, including and especially canned food. It’s an extremely common ingredient in the epoxy linings that cover the metal on the can’s inside.This, most experts agree, is the number one source of human exposure. In Canada, the age group with the highest detected levels of BPA is teenagers, followed by younger kids. These are also the age groups most likely to eat canned foods.This month, a panel of international experts sat down in Ottawa to get to the bottom of the issue of BPA in food. The meeting was sponsored by the World Health Organization, with support from the FDA, Health Canada and the European Food Safety Authority. Their conclusion? That canned food is indeed the main avenue by which we absorb BPA … and it’s not a problem. Their modeling shows that BPA coming in through food consumption matches the quantity going out through urine. BPA does not significantly accumulate in the body, says WHO, and therefore action to remove it from food packaging would be “premature”.Why premature? Because, as WHO acknowledges, there are still several studies suggesting adverse health effects even at very low levels, and finding worse overall health in people who work around BPA, for instance in canneries. Some of the best quality studies have still to report their findings, so the WHO wants to keep its options open. But WHO also didn’t want to hurt industry by causing a public health scare before it knew the facts, so it held the meeting behind closed doors and made participants sign confidentiality agreements. This approach may have backfired. Several manufacturers, apparently unable to stand the strain of not knowing, pre-empted the conference’s findings by announcing plans to remove BPA from their products while the experts were still deliberating. Among these was the world’s largest, Nestlé.But Nestlé only said it would remove BPA from its US products – though many such products will undoubtedly find their way onto Canadian shelves. Different solutions might apply in different parts of the world, said the company, depending partly on local “cultural sensitivities” and consumer preferences. In other words, where the public shows no sign of caring about potential toxicity, manufacturers are unlikely to worry about it either. Get Canadian Medicine news by email or in an RSS reader
- Kryptonite to the rescue? A superglue that can slash heart surgery recovery time shows super promiseWe’ve all been warned of dire consequences if we accidentally get Krazy Glue on our fingers when we’re fixing the lamp the dog knocked over. Many glues are so strong savvy people use them to help close wounds. In fact, they are used in medicine during hip replacements and other procedures. Dr. Paul Fedak, at Calgary’s Foothills Hospital Medical Centre has recently shown that a new superglue can be applied to the sternum after open-heart surgery, with superior results compared to conventional treatment.Last Sunday, over 3,000 health professionals were treated to information on this super adhesive, called Kryptonite, at the Canadian Cardiovascular Conference in Montreal. The results from a trial on 55 patients who had undergone open-chest surgery – during which the breastbone must be cut open – received either standard treatment with steel wire closures (25 patients), or wires along with the superglue (30 patients).The glue, made by Doctors Research Group in the U.S., bonded the bones together within 24 hours, without sticking to any other tissue, while the wires alone took up to eight weeks.Because Kryptonite’s ingredients are derived from components in castor bean oil – fatty acids and calcium carbonate – Dr. Fedak says the stuff is “bio-compatible,” i.e. the polymer forms a porous, very strong bonelike substance, and it doesn’t contain the toxins found in most other bone cements.Recovery time was cut in half and the pain encountered during healing was greatly diminished. Normally, just the thought of coughing, sneezing or even breathing deeply brings on dread to recuperating chest surgery patients. Those treated with the superglue needed far less medication for their pain.Of course, the innovation comes with a price – in the arena of $700. Dr. Fedak, however, believes that the shortened hospital stays and reduced medication needed after operations using Kryptonite would help compensate for this cost.Of the approximate 29,000 chest surgeries performed in Canada annually, it’s highly possible that if the next trial – of 2,000 people – on Kryptonite confirms this study’s results, only high-risk patients (those with internal bleeding or other complications) will not receive this breakthrough treatment in the future. I can’t wait for the results!Milena Katz
- Getting drug addiction treatment on track Implants may trump liquid and pillsMethadone has helped countless people hooked on heroin and prescription pain relievers wean themselves off for over 40 years. A methadone alternative may soon outshine the well-known withdrawal aid in some important ways.Buprenorphine hydrochloride, a semi-synthetic opioid compound used for pain control and detoxification, has been available in pill form for two years. But its downside includes diverting the tablets for sale on the streets and crushing and liquefying them into an injectable – and therefore more potent -- form.A recent study published in the Journal of the American Medical Association (http://jama.ama-assn.org/cgi/content/short/304/14/1576) shows promise for a buprenorphine implant, called Probuphine by its California makers, Titan Pharmaceuticals. One hundred and sixty-three opioid-dependent adults (18-65 years of age) received either four 3-cm long (a centimeter shy of the width of a ping-pong ball), ethylene vinyl acetate and buprenorphine implants, or 4 dummy rods for 6 months. The 108 participants with the real deal received 80 mg per implant. All the subjects were given drug counselling, and urine samples were taken to detect illicit drug use.If anyone felt the slow-release dose from the implants did not combat their cravings sufficiently, they could request sublingual tablets. Over the first 16 weeks, about 60% of the buprenorphine group requested extra doses, while over 90% of the placebo-implanted group did. Urine samples tested negative for illicit opioids more often in the buprenorphine implant group than the placebo group (approximately 40% vs 28%) over the same timeframe. And more of the buprenorphine group opted to stay in the study for the full 24 weeks (66% vs 31%).Cravings and other withdrawal symptoms were generally reduced in the treatment group, although there were minor adverse reactions reported, i.e. discomfort at the implant site, in both groups.Considering that Canada ranks almost as high as Germany and the U.S. for prescription opioid use, a six-month implant may be well worth the trouble – as long as it doesn’t dissuade regular visits to the clinic for counselling.Milena Katz
- Doctor, heal thyself Post-grads ignore their own signs and symptoms of sicknessWe all know the definition of absenteeism: you fall ill, you call in sick, you stay home and nurse your cold. If you think you know the meaning of presenteeism, then, you’d be right: you feel ill, you go to work anyway. Presenteeism has remained a going concern for many medical residents, despite reforms made over the last decade, according to a recent study conducted by the Accreditation Council for Graduate Medical Education.It seems junior docs in specialties as diverse as internal medicine, pediatrics, general surgery and obstetrics/gynecology will risk infecting their patients and co-workers, and risk affecting the quality of their performance more often than what might be prudent, because of the extreme dedication to their jobs. Or, might it as likely be a protection of their image? Often, they don’t want to appear to be shirking their responsibilities in the competitive hospital environments in which they must practice. Some don’t relish finding a replacement, when he or she may also be doing a gruelling 80-hour sleep-deprived week. Plus, add to the mix sincere devotion and empathy for the patients, who would not be familiar or comfortable with the substitute doc.Study co-author Dr. Anupam Jena, a Massachusetts General Hospital medical resident who did not take part in the JAMA-published study (http://jama.ama-assn.org/cgi/content/short/304/11/1166-a?rss=1), admitted to once working overnight, despite developing food-poisoning symptoms. He has company. Of the 537 medical residents anonymously surveyed, almost 58% said they’d worked at least once while sick the previous year, 31% said they’d done so more than once, and at one hospital, a full 100% reported working when sick. Many said they also could not find time to visit a doctor for their symptoms.Despite the unique pressures on these groups of young physicians, isn’t it time that program directors heighten the emphasis on the benefits of being a healthy hospital practitioner – especially during flu season?Milena Katz
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