Medical News Today
- New Study Says Men Are Not Sex Crazed After All Everyone knows the old urban legend that men think about sex every minute of the day, but now that appears to have been debunked. Men are not so sex crazed after all, say researchers from Ohio State University. Their research appears to discredit the persistent stereotype that men think about sex every seven seconds, which would amount to more than 8,000 thoughts about sex in 16 waking hours. In fact, over the course of their study, the median number of young men's thoughts about sex stood at under 19 times per day...
- Cursing Relieves Pain, But Not If Over-Used Cursing can provide effective, short-term pain relief say researchers, but not if over-used: the effect is much greater for people who do not make a habit of it. Richard Stephens and Claudia Umland from the School of Psychology at the University of Keele in the UK, report findings that shed new light on the use of swearing as a response to pain in the 14 November online issue of The Journal of Pain...
- US Organ Shortage - Presumed Consent Not The Solution According to new John Hopkins research, organ donation rates in the United States are not likely to increase by changing from an opt-in process, whereby individuals check a box on their driver's license application for example, to an opt-out process, known as presumed consent, in which a person will automatically donate their organs unless they explicitly object whilst they are alive. Some organ donation advocates press to change the opt-in process to implement a system of presumed consent, as it would be a positive effort to tackle the nation's profound organ shortage...
- Stress Response In Police Officers May Indicate Risk For ... Often stress-related disorders are linked to individuals who work in the firing line. In an investigation led by Dr. Charles Marmar, professor and chair of the Department of Psychiatry at the NYU Langone Medical Center in collaboration with the San Francisco VA Medical Center and the University of California, San Francisco, the researchers examined police recruits during academy training prior to critical incident exposure. They provided the recruits with salivary cortisol at first awakening and after 30 minutes...
- For-Profit Nursing Homes Have Low Staffing and Poor Quali... According to a study published online in advance of print publication in Health Services Research, the largest for-profit nursing homes in the nation deliver considerably lower quality of care as they often have fewer staff nurses compared with non-profit and government-owned nursing homes. The study, led by University of California, San Francisco (UCSF), of care at nursing homes around the nation, is the first to focus only on staffing and quality at the 10 largest for-profit chains...
- Protecting Bones During Weight Loss - Eat Protein-Rich Foods According to an investigation published online in the Journal of Clinical Endocrinology and Metabolism, consuming a calorie controlled diet lower in carbohydrates and higher in protein - primarily from dairy foods - combined with daily exercise has a significantly positive impact on bone health in overweight individuals as well as obese young women. The researchers observed that bone health improvements were particularly evident, because of the high density of bone-supporting nutrients, such as vitamin D, dairy-based protein and calcium...
- Hearing Melodies And Speech Cues - Is There A Central Bra... To a human, hearing the perceptual feature of sound known as pitch is vital. This pitch allows individuals to enjoy music and recognize the inflection of speech. According to prior investigations, there is a particular region in the brain that may be accountable for perceiving pitch. Although, whether this "pitch center" really exists is currently being debated by auditory neuroscientists...
- Fish Baked Or Broiled Reduces Alzheimer's Risk Eating fish once a week is good for brain health, as well as lowering your risk of developing Alzheimer's disease and MCI (Mild Cognitive Impairment), researchers from the University of Pittsburgh School of Medicine explained at the annual meeting of RSNA (Radiological Society of North America), Chicago, yesterday. Cyrus Raji, M.D., Ph.D. said: "This is the first study to establish a direct relationship between fish consumption, brain structure and Alzheimer's risk...
- World AIDS Day: HIV Laws And Policies, New Online Tool On World AIDS Day, an online tool is being launched by the Criminalize Hate Not HIV campaign in order to help individuals living with the disease, campaigners and activists around the world learn more about policies and laws which may directly affect them. The campaign was launched to terminate the use of criminal laws to criminalize HIV transmission, and exposure to HIV. The online tool is also designed to help policy makers find out more about the impact of such legislation...
- Cholesterol-Lowering Lipitor: FDA Okays First Generic Ver... The US Food and Drug Administration (FDA) announced on Wednesday that it has approved the first generic version of the world's top-selling medicine, the cholesterol-lowering drug Lipitor (atorvastatin), currently marketed by Pfizer Inc. Ranbaxy Laboratories Limited, India's largest pharmaceutical company, has gained FDA approval to make generic atorvastatin calcium tablets in 10 milligram, 20 mg, 40 mg, and 80 mg strengths. The tablets will be made by Ohm Laboratories in New Brunswick, New Jersey, says the FDA...
Newswise: MedNews
- Riverview Medical Center Foundation Announces Five New Fo... Domenic M. DiPiero, chairman of the Riverview Medical Center Foundation, is proud to welcome five new members to the board of trustees. The newly elected Foundation Board of Trustees include: William J, Marraccini, Nancy B. Mulheren, Howard Ross, M.D., Richard Saker, and Steve Scopellite.
- Innovative Metabolic Weight Loss Program Perfect Way to S... The Metabolic Weight Loss Program at LifeBridge Health & Fitness near Baltimore, Md., can help a person shed pounds through knowledge of their metabolic rate.
- Food Served in Children's Hospitals Is Largely Unhealthy Given the obesity epidemic among the nation's young, one would hope that children's hospitals would serve as a role model for healthy eating. But hospitals in California fall short, with only 7 percent of entrees classified as "healthy."
- Health Gap has Grown Among Young U.S. Adults Levels of health disparity have increased substantially for people born in the United States after 1980, according to new research.
- Health Gap Has Grown Among Young U.S. Adults, Study Finds Levels of health disparity have increased substantially for people born in the United States after 1980, according to new research.
- Three Pronged Strategy to End the HIV/AIDS Epidemic National Association for People with AIDS (NAPWA) President and CEO Frank Oldham, Jr. Advocates for a Three Pronged Strategy to End the HIV/AIDS Epidemic: Prevention, Research to Lead to Better Treatments, and Leveling the Playing Field for Access to Healthcare and Economic Opportunity
- Blood Cell Test for HIV Treatment Monitoring is Cheaper b... A cheaper laboratory test that helps guide anti-retroviral drug treatment for people with HIV/AIDS may be just as effective as a more sophisticated test, a group of international researchers has found - a discovery that could be particularly important in rural Africa.
- New Approach to Graft-versus-Host Disease Treatment Resul... Scientists at Dana-Farber Cancer Institute have used IL-2, an immune system stimulant, as an immune system suppressor to treat a common, often debilitating side effect of donor stem cell transplantation in cancer patients. The effect, in some cases, was profound.
- Risk Factors for CCSVI are Similar to Risk Factors for De... A preliminary University at Buffalo study of 252 volunteers has found an association between CCSVI and as many as three characteristics widely viewed as possible or confirmed MS risk factors.
- Is It Alzheimer's Disease or Another Dementia? Marker May... New research finds a marker used to detect plaque in the brain may help doctors make a more accurate diagnosis between two common types of dementia - Alzheimer's disease and frontotemporal lobar degeneration (FTLD). The study is published in the November 30, 2011, online issue of Neurology(r), the medical journal of the American Academy of Neurology.
ScienceDaily: Health & Medicine News
- Age-old remedies using white tea, witch hazel and rose ma... Age-old remedies could hold the key to treating a wide range of serious medical problems, as well as keeping skin firmer and less wrinkled, according to scientists. Experts have discovered that white tea, witch hazel and the simple rose hold potential health and beauty properties which could be simply too good to ignore.
- Two out of three medical students do not know when to was... Only 21 percent of surveyed medical students could identify five true and two false indications of when and when not to wash their hands in the clinical setting, according to a new study.
- Cancer cells' DNA repair disrupted to increase radiation ... Shortening end caps on chromosomes in human cervical cancer cells disrupts DNA repair signaling, increases the cells' sensitivity to radiation treatment and kills them more quickly, according to a new study. Researchers would to like see their laboratory findings lead to safer, more effective combination therapies for hard-to-treat pediatric brain cancers. To this end, they are starting laboratory tests on brain cancer cells.
- Children with HIV/AIDS falling through the cracks of trea... Less than one-quarter (23 percent) of children with HIV/AIDS who need treatment are getting it, according to a new report. Although treatment coverage for adults has been steadily climbing and has now reached approximately half of those in need, coverage for children is lagging far behind.
- Danish HIV patients can live as long as the general popul... Researchers who have been following Danish HIV patients for more than fifteen years now see that the patients may live as long as other Danes if they take their medicine.
- MAKS: Drug-free prevention of dementia decline There are many different causes of dementia and, although its progression can be fast or slow, it is always degenerative. Symptoms of dementia include confusion, loss of memory, and problems with speech and understanding. It can be upsetting for the affected person, their relatives and carers. New research shows that a regime of behavioral and mental exercises was able to halt the progression of dementia.
- Is it Alzheimer's disease or another dementia? Marker may... New research finds a marker used to detect plaque in the brain may help doctors make a more accurate diagnosis between two common types of dementia -- Alzheimer's disease and frontotemporal lobar degeneration. The study is published in the Nov. 30, 2011, online issue of Neurology, the medical journal of the American Academy of Neurology.
- Researchers examine role of inflammatory mechanisms in a ... Researchers have found that an inflammatory mechanism known as inflammasome may lead to more damage in the heart following injury such as a heart attack, pointing researchers toward developing more targeted strategies to block the inflammatory mechanisms involved.
- From gene to function: Genome wide study into new gene fu... A new study successfully identifies new genetic variants involved in the formation of platelets and more importantly, defines how genes near these variants affect platelet size and number using a series of biological analyses. This is the largest genome-wide meta-analysis on platelet size and number and involves more than 68,000 individuals from different ancestries.
- Biologists deliver neutralizing antibodies that protect a... Researchers have been studying a group of potent antibodies that have the ability to neutralize HIV in the lab; Their hope is to create a vaccine that makes antibodies with similar properties. Now, biologists have taken one step closer to that goal: They have developed a way to deliver these antibodies to mice and, in so doing, have effectively protected them from HIV infection.
Yahoo! News: Health News
- Obama on AIDS: `We can beat this disease' (AP) AP - President Barack Obama set an ambitious goal Thursday for significantly increasing access to life-saving AIDS drugs for people in the U.S. and around the world, as he announced a renewed American commitment to ending a pandemic that has killed 30 million people.
- NYC recommends AIDS drugs for any person with HIV (AP) AP - Health officials in the nation's largest city are recommending that any residents living with HIV be offered AIDS drugs as soon as the virus is diagnosed, an aggressive move that has been shown to prolong life and stem the spread of the disease.
- FDA examines level of arsenic in apple juice (AP) AP - The Food and Drug Administration is considering tightening restrictions for the levels of arsenic allowed in apple juice after consumer groups pushed the agency to crack down on the contaminant.
- Americans mixed on adequacy of cancer screenings: poll ... Reuters - Many Americans are satisfied with how often they are screened for cancer but some say they are not screened often enough, while a growing body of evidence suggests too much screening for certain types of cancer may do more harm than good, a Gallup poll showed.
- Women's High Blood Sugar Linked to Colorectal Cancer: Stu... HealthDay - WEDNESDAY, Nov. 30 (HealthDay News) -- There may be a link between high blood sugar levels and an increased risk of colorectal cancer in older women, a new study finds.
- Lobular Breast Cancer Linked to Paternal Cancer History ... HealthDay - WEDNESDAY, Nov. 30 (HealthDay News) -- Women with lobular breast cancer are nearly twice as likely as those with other forms of breast cancer to have a father who had cancer, especially prostate cancer, a new study finds.
- Medicare to cover obesity counseling, screening (Reu... Reuters - The U.S. Medicare program for the elderly will cover counseling for obesity in an effort to reduce the condition that has reached epidemic proportions and leads to serious health problems.
- Regular Sex May Be Key to Happy Marriage for Seniors ... HealthDay - MONDAY, Nov. 21 (HealthDay News) -- Among older married Americans, an active sex life is associated with greater happiness with their marriages and with life in general, according to a new study.
- Two governors petition for medical marijuana (Reuters) Reuters - The governors of Washington state and Rhode Island filed a petition with the U.S. Drug Enforcement Administration on Wednesday that would allow doctors to legally prescribe marijuana as a medical treatment.
- Children with HIV in Asia resistant to AIDS drugs (R... Reuters - Teenagers in Asia receiving treatment for HIV are showing early signs of osteoporosis and children as young as five are becoming resistant to AIDS drugs, an anti-AIDS group said on Thursday, urging more attention be given to young HIV patients.
BBC World Health News
- Variation in coffee shop caffeine High Street coffee shops could pose a risk to pregnant women because of big variations in the amount of caffeine in each cup, research suggests.
- Cancer boy better after treatment A schoolboy diagnosed with a rare form of childhood cancer in 2006 is defying medical opinion as his condition improves.
- Strike hits non-urgent NHS care Hospitals have had to cancel thousands of routine operations in the biggest strike in the NHS for more than 20 years.
- NICE blocks eye drug for diabetes A drug that could save the sight of people with diabetes will not be made available on the NHS in England and Wales.
- Too many headers 'damage brain' Frequently heading a football can lead to brain injury, warn doctors who say they have found evidence on brain scans.
- Scan spots 'curable' hypertension Doctors say they have found a medical test that can diagnose the most common curable cause of high blood pressure.
- Brain find sheds light on autism Cells taken from people with a rare syndrome linked to autism could help scientists understand the origins of the condition.
- Norway killer is declared insane Psychiatrists assessing Norwegian mass killer Anders Behring Breivik conclude he is a paranoid schizophrenic and should be treated as such.
- 'Right to die' man seeks ruling A severely disabled man from Wiltshire is asking the High Court to allow his doctor to end his life "lawfully".
- Fifth of patients 'shun HIV test' As UK experts call for universal HIV testing in a bid to reduce infections, latest figures reveal a fifth offered the test refuse to have it.
MedPageToday Headlines
- Feds Probe Coverage of Psych Drugs Used in Nursing Homes WASHINGTON (MedPage Today) -- Companies that administer Medicare Part D drug programs for seniors cannot tell whether antipsychotics and other drugs they cover are being used for medically accepted indications, according to a new report from the Office of the Inspector General.
- Noncardiac Chest Pain Has CV Risk for Psych Patients (CME... (MedPage Today) -- Chest pain without a cardiac cause can portend a rapid demise for patients with severe mental illness, according to a population-based study from Scotland.
- Stent 'Connectors' Key to Longitudinal Weakness (CME/CE) (MedPage Today) -- It may be the number of connectors in a stent that determines whether or not it is more susceptible to longitudinal compression, according to a bench-testing study.
- Protected Patient Data Increasingly Being Lost, Stolen (MedPage Today) -- Nearly all healthcare organizations responding to a survey -- 96% -- reported that patient or related information has been lost, stolen, or otherwise compromised within the last two years.
- Structured Group Activity Slows Dementia Progress (CME/CE) (MedPage Today) -- Highly structured group therapy, including both motor and cognitive stimulation, slows the progress of degenerative dementia, according to a randomized, controlled, longitudinal study of nursing home patients in Bavaria.
- High Glucose Levels Raise Colon Cancer Risk in Women (CME... (MedPage Today) -- Older women who have high levels of serum glucose are at nearly double the risk for colorectal cancer, a longitudinal study found.
- Patients Can Safely Manage Blood Thinners Themselves (CME... (MedPage Today) -- Anticoagulant monitoring and dosing managed by patients at home is safe and decreases clotting risk, a meta-analysis found.
- RSNA: A Fish a Week Keeps the Brain at Its Peak CHICAGO (MedPage Today) -- Eating fish at least once a week could help lower older patients' risk of developing dementia, researchers said here.
- Interleukin-2 Works for Autoimmune Diseases (CME/CE) (MedPage Today) -- Low-dose interleukin-2 immunotherapy appears to be safe and effective in treating two immune-mediated diseases, two small, uncontrolled studies showed.
- Amyloid Ligand Tells Alzheimer's from Dementia (CME/CE) (MedPage Today) -- The amyloid ligand Pittsburgh B and fluorodeoxyglucose both accurately discriminated between Alzheimer's disease and frontotemporal lobar degeneration in positron emission tomography scans of the brain, according to the results of a new study.
Reuters: Health News
- Obama sets new U.S. goal on fighting AIDS WASHINGTON (Reuters) - President Barack Obama vowed on Thursday to bolster U.S. efforts to fight AIDS, setting a new goal of providing treatment to 6 million people worldwide, up from the earlier goal of 4 million.
- Children with HIV in Asia suffer resistance to AIDS drugs HONG KONG (Reuters) - Teenagers in Asia receiving treatment for HIV are showing early signs of osteoporosis and children as young as five are becoming resistant to AIDS drugs, an anti-AIDS group said on Thursday, urging more attention be given to young HIV patients.
- Insight: Diabetes breakthrough stalled in safety debate CHICAGO (Reuters) - It's a dream of medical science that looks tantalizingly within reach: the artificial pancreas, a potential breakthrough treatment for the scourge of type 1 diabetes.
- FDA: Diabetes device plan may help patients faster CHICAGO (Reuters) - The U.S. Food and Drug Administration issued new guidelines on Thursday for the development of a potentially revolutionary device to treat type 1 diabetes that will give manufacturers 'maximum flexibility' in getting it to U.S. patients.
- Children with HIV in Asia resistant to AIDS drugs HONG KONG (Reuters) - Teenagers in Asia receiving treatment for HIV are showing early signs of osteoporosis and children as young as five are becoming resistant to AIDS drugs, an anti-AIDS group said on Thursday, urging more attention be given to young HIV patients.
- Gender inequality persists in multitasking: study NEW YORK (Reuters) - Men may be helping more in the home but working women still do more multitasking in U.S. families than their partners and are finding it stressful, according to a new study.
- Americans mixed on adequacy of cancer screenings: poll (Reuters) - Many Americans are satisfied with how often they are screened for cancer but some say they are not screened often enough, while a growing body of evidence suggests too much screening for certain types of cancer may do more harm than good, a Gallup poll showed.
- Gender inequality persists in multitasking: study NEW YORK (Reuters) - Men may be helping more in the home but working women still do more multitasking in U.S. families than their partners and are finding it stressful, according to a new study.
- Germany offers therapy to child sex abuse victims BERLIN (Reuters) - Germany will offer every victim of child sex abuse 10,000 euros ($13,000) worth of therapy from a 100 million euro fund set up to address a scandal centered on Catholic schools.
- Most insurers met spending limits under law: GAO (Reuters) - Most U.S. health insurers last year would have satisfied the much-disputed spending rules under President Barack Obama's healthcare reform, according to a new report by a congressional watchdog agency.
Medscape Headlines
- Risk of Ovarian Tumors After Ovarian Stimulation for IVFR... Is ovarian stimulation for IVF potentially putting women at risk for ovarian malignancies? Human Reproduction
- Healthcare Accreditation Systems: Performance MeasuresHea... What types of measures are currently in place in this country to evaluate the effectiveness of hospital accreditation programs? International Journal for Quality in Health Care
- Type 2 Diabetes Risk Variants and Colorectal Cancer RiskT... Are patients with type 2 diabetes more likely to develop colorectal cancer than non-diabetics and, if so, why? Gut
- Diagnosis and Treatment of Psychogenic ParkinsonismDiagno... Psychogenic parkinsonism is a rare disorder characterized by movement abnormalities usually associated with Parkinson's disease--but with no organic cause. How should a suspected case be approached? Journal of Neurology, Neurosurgery, and Psychiatry
- Diabetes and Prostate Cancer Risk in the REDUCE TrialDiab... Is there a link between diabetes, obesity and prostate cancer risk? The REDUCE trial investigates. Prostate Cancer and Prostatic Diseases
- Is 'Mild Primary Hyperparathyroidism' Really 'Insidious'?... Knowledge about the natural history of mild hyperparathyroidism has increased over the last 2 decades. Clinical Endocrinology
- Late-onset Neutropenia Following Rituximab TherapyLate-on... Late-onset neutropenia is emerging as a common adverse effect of rituximab when used in the treatment of autoimmune diseases. Is this late effect as widespread as it seems? Expert Review of Hematology
- Largest Biobank in the US Poised to Advance KnowledgeLarg... RPGEH is poised to provide unprecedented opportunities to advance knowledge of genetic and environmental predictors of disease and treatment responses. Medscape Medical News
- Statins and Alzheimer's: Moving the Field ForwardStatins ... Medscape Medical News
- Deletion on Chromosome 2 Linked to Epilepsy, AutismDeleti... Deletion of the MBD5 gene has been identified in all individuals affected by a microdeletion syndrome characterized by intellectual disability, epilepsy, and autism spectrum disorder. Medscape Medical News
AP Health News
- Obama on AIDS: `We can beat this disease' WASHINGTON (AP) -- President Barack Obama set an ambitious goal Thursday for significantly increasing access to life-saving AIDS drugs for people in the U.S. and around the world, as he announced a renewed American commitment to ending a pandemic that has killed 30 million people....
- NYC recommends AIDS drugs for any person with HIV NEW YORK (AP) -- Health officials in the nation's largest city are recommending that any residents living with HIV be offered AIDS drugs as soon as the virus is diagnosed, an aggressive move that has been shown to prolong life and stem the spread of the disease....
- FDA examines level of arsenic in apple juice WASHINGTON (AP) -- The Food and Drug Administration is considering tightening restrictions for the levels of arsenic allowed in apple juice after consumer groups pushed the agency to crack down on the contaminant....
- Hope for new AIDS protection seen in mouse study NEW YORK (AP) -- As scientists struggle to find a vaccine to prevent infection with the AIDS virus, a study in mice suggests hope for a new approach - one that doctors now want to test in people....
- China expects 48,000 new HIV cases this year BEIJING (AP) -- China will have about 780,000 people infected with the AIDS virus by the end of this year, state media reported Wednesday, with most having contracted it through heterosexual sex....
- Inspector highlights psych drug use among elderly WASHINGTON (AP) -- Government inspectors told lawmakers Wednesday that Medicare officials need to do more to stop doctors from prescribing powerful psychiatric drugs to nursing home patients with dementia, an unapproved practice that has flourished despite repeated government warnings....
- China prepares for big entry into vaccine market BEIJING (AP) -- The world should get ready for a new Made in China product - vaccines....
- Pfizer maneuvers to protect Lipitor from generics TRENTON, N.J. (AP) -- Lipitor is so valuable that Pfizer is practically paying people to keep taking its blockbuster cholesterol medicine after generic competition hits the U.S. market this week....
- Just 1 in 4 with HIV have infection under control ATLANTA (AP) -- Only about 1 in 4 Americans with the AIDS virus have the infection under control with medications, federal health officials said Tuesday....
- AP IMPACT: More kids skip school shots in 8 states ATLANTA (AP) -- A rising number of parents in more than half of states are opting out of school shots for their kids. And in eight states, more than 1 in 20 public school kindergartners do not get all the vaccines required for attendance, an Associated Press analysis found....
NYTimes Health News
- Doctor and Patient: Doctor and Patient: The Doctor as Poet A medical school poetry contest that elicited a surprising 160 entries has prompted a discussion about the value of medical poetry, which physicians say can help address the emotional demands of doctoring.
- DNA Sequencing Caught in Deluge of Data DNA sequencing is becoming faster and cheaper, outrunning the ability to store, transmit and analyze the data.
- Federal Marijuana Classification Should Change, Gregoire ... The governors of Washington and Rhode Island say states that allow medical marijuana are not able to regulate the industry.
- To Stop AIDS, N.Y.C. Wants Drugs Given Sooner for H.I.V. New York City’s health commissioner is pushing an aggressive change in the city policy toward the virus that causes AIDS, saying his recommendation to doctors will reduce transmission.
- Recipes for Health: Steamed Cod or Sea Bass Salad — Rec... A refreshing first course or light main dish, this salad has vivid Middle Eastern flavors.
- Senators Question Plan to Stall Generic Lipitor Three senators asked Pfizer to detail their agreements to block prescriptions of generic versions of Lipitor, saying they were against the idea of drug makers manipulating the marketplace.
- Phys Ed: How Exercise Benefits the Brain New research suggests that surges in a brain protein after exercise may play a particular role in improving memory and recall.
- Generic Lipitor Sets Off an Aggressive Push by Pfizer Pfizer’s aggressive strategy may offer lessons for drug makers facing similar losses of patent protection for other blockbuster drugs over the next few years.
- College Players Move Concussions Issue Into the Courtroom A class-action suit filed in Illinois claims the N.C.A.A. has been negligent regarding awareness and treatment of brain injuries to athletes.
- The Certainty of Memory Has Its Day in Court Rather than the centerpiece of prosecution, witness testimony should be viewed more like trace evidence, scientists say, with the same fragility and vulnerability to contamination.
USAToday Health News
- What's trendy in baby names? Lists help BabyCenter.com's new top 100 shows celebrity baby names are rising.
- An end to AIDS? In USA, complacency is a major barrier Is it too soon to imagine an end to AIDS? Maybe not. But complacency gets in the way.
- FDA examines level of arsenic in apple juice The debate over the safety of fruit juice consumed by Americans escalated Wednesday with the release of a Consumer Reports study that found many ...
- Medicare anti-obesity initiative triggers treatment debate A Medicare anti-obesity initiative has triggered an old debate about who can best help people slim down.
- FDA approves generic cholesterol-lowering Lipitor India's largest maker of generic drugs won approval late Wednesday to sell a generic version of cholesterol blockbuster Lipitor.
- Multitasking stresses out working moms more than dads American working moms do a whole lot multitasking-- and seem more stressed by it than working dads, a new study shows.
- Report examines psych med use among foster kids Federal lawmakers will hold a hearing to examine a study on the high rates at which foster children are prescribed powerful psychotropic dru ...
- San Fran Burger Kings also charge for kids meals A new city law bans free toys with kids meals that are high in fat, sugar and salt.
- Beyond chickens and bees: Urban farmers try goats Urban goat farming is part of a nationwide movement to eat food produced locally sometimes as locally as our backyards.
- Most U.S. drivers engage in 'distracting' behaviors Whether it's talking on cellphones or eating a most of adult drivers in the U.S. admit to being dangerously distracted while driving.
msnbc.com:
- Indian drugmaker launches generic Lipitor India's largest maker of generic drugs won approval Wednesday to sell a generic version of cholesterol blockbuster Lipitor. The world's top-selling drug ever lost U.S. patent protection earlier in the day.
- NYC to offer AIDS drugs to early-diagnosed HIV patients City health officials said Thursday they are recommending that any person living with HIV be offered AIDS drugs as soon as they are diagnosed with the virus, an aggressive move that has been shown to prolong life and stem the spread of the disease.
- Eating fish once a week may ward off Alzheimer's Eating fish may keep the brain healthy and reduce the risk of Alzheimer's disease, a new study says.
- McDonald's finds way around 'Happy Meal ban' San Francisco's so-called Happy Meal ban goes into effect Thursday, but McDonald's has already found a way around it — by charging for the toy.
- Few Americans with HIV have virus under control Health officials say only 1 in 4 Americans with the AIDS virus have the infection under control with medications.
- New England sees puzzling rise in Legionnaires' disease
- Opinion: Officials wrong to put obese boy in foster care An 8-year-old Ohio boy weighing 200 pounds was taken by officials who said his mother wasn't doing enough to control his weight. That was the wrong call, says Arthur Caplan, msnbc.com contributor and professor of bioethics at the University of Pennsylvania in Philadelphia.
- Holiday dreads: Crowds, relatives and fake smiles Most of us dread long lines, expanding waistlines and going into debt during the holiday season. But having smile? According to Consumer Reports, 15 percent dread the idea of having to be nice.
- A second chance for faulty food? It's OK with FDA Moldy applesauce repackaged as canned goods and fruit cups sparked a furor, but it's actually quite common for food processors to turn imperfect, mislabled or contaminated foods, even ice cream, into edible — and profitable — goods. The FDA calls it "reconditioning."
- We don't actually salivate at the thought of food Mom's lasagna. Homemade chocolate chip cookies straight from the oven. Is your mouth watering at the very thought of some of these foods? No, it isn't, a new study suggests, because that's not something humans are capable of doing.
MSN Health News
- Experts Urge Posting Meat, Poultry Inspection Data on Web
- More Exercise Could Make For Better Sleep: Study
- Many Ignore Symptoms of Lung Disease, Study Finds
- Multitasking Stresses Out Working Moms More Than Dads
- Younger Americans Face Greater Health Disparities: Study
- How to Stay Flu-Free for the Holidays
- Despite Advances, HIV/AIDS Still Takes Heavy Emotional Toll
- AIDS Research Holds Promise for Reducing HIV Transmission...
- Self-Monitoring of Blood Thinner May Halve Clot Risk
- Drug May Dampen Dangerous Side Effect of Stem Cell Transp...
CBS Health News
- FDA mulls tighter arsenic restrictions for apple juice Consumer Reports study found 10 percent of apple juices contaminated
- Obama on AIDS: "We can beat this disease" In event to mark World AIDS Day 2011, president announces ambitious new effort to curb HIV/AHDS in U.S., world
- Moms have it harder than dads? "Multitasking" study says yes Working mothers multitask more - and enjoy it less - than their male counterparts, researchers say
- Video: Lipitor cholesterol drug to go generic Lipitor cholesterol pills will be sold in generic form, bringing the co-payment from $25 per month to $10 per month. Terrell Brown reports.
- San Francisco toy giveaway ban spotlights childhood obesity McDonald's said 10-cent charge for Happy Meal toy will be donated to charity
- HIV patients need AIDS drugs immediately, NYC recommends New recommendations from health officials suggest immediate treatment for city's 110,000 HIV patients
- Obama offering new plan to combat HIV/AIDS New initiatives would increase access to antiretroviral drugs and boost spending on treatment
- New HIV treatment shows 100% protection in mice: Humans n... Treatment injects gene into cells that increases immune system defenses
- World AIDS Day 2011: What's happening where From flash mob dancing in Romania to fireworks in Australia, activists spread life-saving message
- Poll reveals dangerous stuff motorists do behind the wheel 86 percent of polled drivers eat behind the wheel, 7 percent watch videos
BBC UK Health News
- Strike hits non-urgent NHS care Hospitals have had to cancel thousands of routine operations in the biggest strike in the NHS for more than 20 years.
- Variation in coffee shop caffeine High Street coffee shops could pose a risk to pregnant women because of big variations in the amount of caffeine in each cup, research suggests.
- Cancer boy better after treatment A schoolboy diagnosed with a rare form of childhood cancer in 2006 is defying medical opinion as his condition improves.
- Night closure for Stafford's A&E Staff at Stafford Hospital prepare to close the A&E department at night as part of a three-month plan.
- NHS boards facing £50m shortfall Health boards face a potential shortfall of nearly £50m, despite the Welsh government warning that they should not expect a bailout.
- NICE blocks eye drug for diabetes A drug that could save the sight of people with diabetes will not be made available on the NHS in England and Wales.
- Wi-fi laptops 'may damage sperm' Scientists are questioning if using wi-fi on a laptop could harm a man's fertility, after lab work suggests ejaculated sperm can be damaged by exposure.
- Paralysed man seeks right to die A severely-disabled man is asking the High Court to allow his doctor to end his life "lawfully", challenging legislation on murder and so-called mercy killing.
- Clinic calls up after Speed death The Chief Executive of the Sporting Chance clinic says he has been contacted by 10 professional footballers since Gary Speed's death.
- Fifth of patients 'shun HIV test' As UK experts call for universal HIV testing in a bid to reduce infections, latest figures reveal a fifth offered the test refuse to have it.
Massachusetts Medical Society: New England Journal of Medicine: Table of Contents
- Balancing Coverage Affordability and Continuity under a B... New England Journal of Medicine, Volume 0, Issue 0, Ahead of Print.
- Making Sense of the New Cervical-Cancer Screening Guidelines New England Journal of Medicine, Volume 0, Issue 0, Ahead of Print.
- Facing a “Slow-Motion Disaster” — The UN Meeting on... New England Journal of Medicine, Volume 0, Issue 0, Ahead of Print.
- Niacin at 56 Years of Age — Time for an Early Retirement? New England Journal of Medicine, Volume 0, Issue 0, Ahead of Print.
- Niacin in Patients with Low HDL Cholesterol Levels Receiv... New England Journal of Medicine, Volume 0, Issue 0, Ahead of Print.
- Needed: Pragmatic Clinical Trials for Statin-Intolerant P... New England Journal of Medicine, Volume 0, Issue 0, Ahead of Print.
- Dronedarone in Atrial Fibrillation — Jekyll and Hyde? New England Journal of Medicine, Volume 0, Issue 0, Ahead of Print.
- Dronedarone in High-Risk Permanent Atrial Fibrillation New England Journal of Medicine, Volume 0, Issue 0, Ahead of Print.
- A New Era in Secondary Prevention after Acute Coronary Sy... New England Journal of Medicine, Volume 0, Issue 0, Ahead of Print.
- Thrombin-Receptor Antagonist Vorapaxar in Acute Coronary ... New England Journal of Medicine, Volume 0, Issue 0, Ahead of Print.
NEJM This Week - Audio Summaries
- NEJM This Week - December 1, 2011 This summary covers the issue of December 1, 2011. Featured are articles on low-dose interleukin-2 in chronic GVHD, low-dose interleukin-2 in HCV vasculitis, statins for regression of coronary atherosclerosis, full drug coverage after myocardial infarction, and immunosuppression and stroke; review articles on genes, genomes, and cardiovascular disease and on systemic lupus erythematosus; a Clinical Problem-Solving article describing a hidden solution; and Perspective articles on habits of high-value health care organizations, on 2012: a watershed election for health care, on varied physician responses to reimbursement change, and on seeing eye to eye.
- NEJM This Week - November 24, 2011 This summary covers the issue of November 24, 2011. Featured are articles on treating obesity in primary care practice, anticoagulant regimens for non-ST-elevation myocardial infarction, daily or intermittent budesonide for recurrent wheezing, and hospitalizations for adverse drug events; a review article on screening for prostate cancer; a case report of a woman with shortness of breath and chest pain; and Perspective articles on screening for prostate cancer and on the MCAT.
- NEJM This Week - November 17, 2011 This summary covers the issue of November 17, 2011. Featured are articles on the first results for malaria vaccine in African children; childhood adiposity and cardiovascular risk; maintenance therapy in lupus nephritis; ADHD drugs and serious cardiovascular events; and beta-cell failure, stress, and type 2 diabetes; a review article on extracorporeal membrane oxygenation for ARDS in adults; a case report of a woman with postpartum leukocytosis and gram-positive bacteremia; and Perspective articles on the public, political parties, and stem-cell research; on war, drought, malnutrition, and measles in Somalia; and on proposals for paying for an SGR repeal.
- NEJM This Week - November 10, 2011 This summary covers the issue of November 10, 2011. Featured are articles on the E. coli outbreak in Germany, N-acetylcysteine in alcoholic hepatitis, and early liver transplantation for alcoholic hepatitis; review articles on sudden, unexpected death in epilepsy and on the human plasma lipidome; a case report of a man with memory loss and partial seizures; and Perspective articles on the final rule for the Medicare shared savings, on harnessing electronic data for safer care, on evidence-based medicine in the EMR era, and on cost-effectiveness and U.S. vaccination policy.
JAMA current issue
- Is Anti-TNF Therapy Safer Than Previously Thought? [Edito...
- Initiation of Tumor Necrosis Factor-{alpha} Antagonists a... Context Although tumor necrosis factor (TNF)-α antagonists are increasingly used in place of nonbiologic comparator medications, their safety profile remains incomplete.Objectives To determine whether initiation of TNF-α antagonists compared with nonbiologic comparators is associated with an increased risk of serious infections requiring hospitalization.Design, Setting, and Patients Within a US multi-institutional collaboration, we assembled retrospective cohorts (1998-2007) of patients with rheumatoid arthritis (RA), inflammatory bowel disease (IBD), and psoriasis, psoriatic arthritis, or ankylosing spondylitis (psoriasis and spondyloarthropathies) combining data from Kaiser Permanente Northern California, New Jersey and Pennsylvania Pharmaceutical Assistance programs, Tennessee Medicaid, and national Medicaid/Medicare. TNF-α antagonists and nonbiologic regimens were compared in disease-specific propensity score (PS)–matched cohorts using Cox regression models with nonbiologics as the reference. Baseline glucocorticoid use was evaluated as a separate covariate.Main Outcome Measure Infections requiring hospitalization (serious infections) during the first 12 months after initiation of TNF-α antagonists or nonbiologic regimens.Results Study cohorts included 10 484 RA, 2323 IBD, and 3215 psoriasis and spondyloarthropathies matched pairs using TNF-α antagonists and comparator medications. Overall, we identified 1172 serious infections, most of which (53%) were pneumonia and skin and soft tissue infections. Among patients with RA, serious infection hospitalization rates were 8.16 (TNF-α antagonists) and 7.78 (comparator regimens) per 100 person-years (adjusted hazard ratio [aHR], 1.05 [95% CI, 0.91-1.21]). Among patients with IBD, rates were 10.91 (TNF-α antagonists) and 9.60 (comparator) per 100 person-years (aHR, 1.10 [95% CI, 0.83-1.46]). Among patients with psoriasis and spondyloarthropathies, rates were 5.41 (TNF-α antagonists) and 5.37 (comparator) per 100 person-years (aHR, 1.05 [95% CI, 0.76-1.45]). Among patients with RA, infliximab was associated with a significant increase in serious infections compared with etanercept (aHR, 1.26 [95% CI, 1.07-1.47]) and adalimumab (aHR, 1.23 [95% CI, 1.02-1.48]). Baseline glucocorticoid use was associated with a dose-dependent increase in infections.Conclusion Among patients with autoimmune diseases, compared with treatment with nonbiologic regimens, initiation of TNF-α antagonists was not associated with an increased risk of hospitalizations for serious infections.
- Factors Associated With Treatment Response to Etanercept ... Context Since the introduction of biologic therapies, the pharmacological treatment approach for juvenile idiopathic arthritis (JIA) has changed substantially, with achievement of inactive disease as a realistic goal.Objective To determine the response to therapy after initiation of etanercept therapy among patients with JIA and to examine the association between baseline factors and response to etanercept treatment.Design, Setting, and Patients The Arthritis and Biologicals in Children Register, an ongoing prospective observational study since 1999, includes all Dutch JIA patients who used biologic agents. All biologically naive patients who started etanercept before October 2009 were included, with follow-up data to January 2011. Among the 262 patients, 185 (71%) were female, 46 (18%) had systemic-onset, and the median age at initiation of etanercept treatment was 12.4 years.Main Outcome Measures Excellent response (inactive disease or discontinuation earlier due to disease remission), intermediate response (more than 50% improvement from baseline, but no inactive disease), and poor response (less than 50% improvement from baseline or discontinuation earlier due to ineffectiveness or intolerance) evaluated 15 months after initiation of etanercept.Results At 15 months after treatment initiation, 85 patients (32%) were considered excellent responders; 92 (36%), intermediate responders; and 85 (32%), poor responders. Compared with an intermediate or poor response, an excellent response was associated with lower baseline disability score (range, 0-3 points, with 0 being the best score; adjusted odds ratio [OR] per point increase, 0.49; 95% CI, 0.33-0.74); fewer disease-modifying antirheumatic drugs (DMARD) (including methotrexate) used before initiating etanercept (adjusted OR per DMARD used, 0.64; 95% CI, 0.43-0.95), and younger age at onset (adjusted OR per year increase, 0.92; 95% CI, 0.84-0.99). Compared with an intermediate or excellent response, a poor response was associated with systemic JIA (adjusted OR systemic vs nonsystemic categories, 2.92; 95% CI, 1.26-6.80), and female sex (adjusted OR female vs male, 2.16; 95% CI, 1.12-4.18). Within the first 15 months of etanercept treatment, 119 patients experienced 1 or more infectious, noninfectious, or serious adverse events, including 37 among those with an excellent response, 36 with an intermediate response, and 46 with a poor response. Within the first 15 months of treatment, 61 patients discontinued etanercept treatment, including 4 with an excellent response, 0 with an intermediate response, and 57 with a poor response. In a secondary analysis of 262 patients with a median follow-up of 35.6 months after initiation of etanercept, a range of 37% to 49% of patients reached inactive disease. The mean adherence to etanercept was 49.2 months (95% CI, 46.4-52.0) for patients with an excellent response after 15 months, 47.5 months (95% CI, 44.9-50.1) for patients with an intermediate response, and 17.4 months (95% CI, 13.6-21.2) for patients with a poor response.Conclusions Among patients with JIA who initiated treatment with etanercept, one-third achieved an excellent response, one-third an intermediate response, and one-third a poor response to therapy. Achievement of an excellent response was associated with low baseline disability scores, DMARDs used before initiating etanercept, and younger age at onset of JIA. Achievement of a poor treatment response was associated with systemic JIA and female sex.
- An 86-Year-Old Woman With Gastrointestinal Bleeding While...
- This Week in JAMA [This Week in JAMA]
- Dosing Clopidogrel Based on CYP2C19 Genotype and the Effe... Context Variants in the CYP2C19 gene influence the pharmacologic and clinical response to the standard 75-mg daily maintenance dose of the antiplatelet drug clopidogrel. Objective To test whether higher doses (up to 300 mg daily) improve the response to clopidogrel in the setting of loss-of-function CYP2C19 genotypes. Design, Setting, and Patients ELEVATE-TIMI 56 was a multicenter, randomized, double-blind trial that enrolled and genotyped 333 patients with cardiovascular disease across 32 sites from October 2010 until September 2011. Interventions Maintenance doses of clopidogrel for 4 treatment periods, each lasting approximately 14 days, based on genotype. In total, 247 noncarriers of a CYP2C19*2 loss-of-function allele were to receive 75 and 150 mg daily of clopidogrel (2 periods each), whereas 86 carriers (80 heterozygotes, 6 homozygotes) were to receive 75, 150, 225, and 300 mg daily. Main Outcome Measures Platelet function test results (vasodilator-stimulated phosphoprotein [VASP] phosphorylation and VerifyNow P2Y12 assays) and adverse events. Results With 75 mg daily, CYP2C19*2 heterozygotes had significantly higher on-treatment platelet reactivity than did noncarriers (VASP platelet reactivity index [PRI]: mean, 70.0%; 95% CI, 66.0%-74.0%, vs 57.5%; 95% CI, 55.1%-59.9%, and VerifyNow P2Y12 reaction units [PRU]: mean, 225.6; 95% CI, 207.7-243.4, vs 163.6; 95% CI, 154.4-173.9; P < .001 for both comparisons). Among CYP2C19*2 heterozygotes, doses up to 300 mg daily significantly reduced platelet reactivity, with VASP PRI decreasing to 48.9% (95% CI, 44.6%-53.2%) and PRU to 127.5 (95% CI, 109.9-145.2) (P < .001 for trend across doses for both). Whereas 52% of CYP2C19*2 heterozygotes were nonresponders (≥230 PRU) with 75 mg of clopidogrel, only 10% were nonresponders with 225 or 300 mg (P < .001 for both). Clopidogrel, 225 mg daily, reduced platelet reactivity in CYP2C19*2 heterozygotes to levels achieved with standard clopidogrel, 75 mg, in noncarriers (mean ratios of platelet reactivity, VASP PRI, 0.92; 90% CI, 0.85-0.99, and PRU, 0.94; 90% CI, 0.84-1.04). In CYP2C19*2 homozygotes, even with 300 mg daily of clopidogrel, mean VASP PRI was 68.3% (95% CI, 44.9%-91.6%) and mean PRU, 287.0 (95% CI, 170.2-403.8). Conclusion Among patients with stable cardiovascular disease, tripling the maintenance dose of clopidogrel to 225 mg daily in CYP2C19*2 heterozygotes achieved levels of platelet reactivity similar to that seen with the standard 75-mg dose in noncarriers; in contrast, for CYP2C19*2 homozygotes, doses as high as 300 mg daily did not result in comparable degrees of platelet inhibition. Trial Registration clinicaltrials.gov Identifier: NCT01235351
- Urinary Sodium and Potassium Excretion and Risk of Cardio... Context The precise relationship between sodium and potassium intake and cardiovascular (CV) risk remains uncertain, especially in patients with CV disease. Objective To determine the association between estimated urinary sodium and potassium excretion (surrogates for intake) and CV events in patients with established CV disease or diabetes mellitus. Design, Setting, and Patients Observational analyses of 2 cohorts (N = 28 880) included in the ONTARGET and TRANSCEND trials (November 2001-March 2008 from initial recruitment to final follow-up). We estimated 24-hour urinary sodium and potassium excretion from a morning fasting urine sample (Kawasaki formula). We used restricted cubic spline plots to describe the association between sodium and potassium excretion and CV events and mortality, and to identify reference categories for sodium and potassium excretion. We used Cox proportional hazards multivariable models to determine the association of urinary sodium and potassium with CV events and mortality. Main Outcome Measures CV death, myocardial infarction (MI), stroke, and hospitalization for congestive heart failure (CHF). Results At baseline, the mean (SD) estimated 24-hour excretion for sodium was 4.77 g (1.61); and for potassium was 2.19 g (0.57). After a median follow-up of 56 months, the composite outcome occurred in 4729 (16.4%) participants, including 2057 CV deaths, 1412 with MI, 1282 with stroke, and 1213 with hospitalization for CHF. Compared with the reference group with estimated baseline sodium excretion of 4 to 5.99 g per day (n = 14 156; 6.3% participants with CV death, 4.6% with MI, 4.2% with stroke, and 3.8% admitted to hospital with CHF), higher baseline sodium excretion was associated with an increased risk of CV death (9.7% for 7-8 g/day; hazard ratio [HR], 1.53; 95% CI, 1.26-1.86; and 11.2% for >8 g/day; HR, 1.66; 95% CI, 1.31-2.10), MI (6.8%; HR, 1.48; 95% CI, 1.11-1.98 for >8 g/day), stroke (6.6%; HR, 1.48; 95% CI, 1.09-2.01 for >8 g/day), and hospitalization for CHF (6.5%; HR, 1.51; 1.12-2.05 for >8 g/day). Lower sodium excretion was associated with an increased risk of CV death (8.6%; HR, 1.19; 95% CI, 1.02-1.39 for 2-2.99 g/day; 10.6%; HR, 1.37; 95% CI, 1.09-1.73 for <2 g/day), and hospitalization for CHF (5.2%; HR, 1.23; 95% CI, 1.01-1.49 for 2-2.99 g/day) on multivariable analysis. Compared with an estimated potassium excretion of less than 1.5 g per day (n = 2194; 6.2% with stroke), higher potassium excretion was associated with a reduced risk of stroke (4.7% [HR, 0.77; 95% CI, 0.63-0.94] for 1.5-1.99 g/day; 4.3% [HR, 0.73; 95% CI, 0.59-0.90] for 2-2.49 g/day; 3.9% [HR, 0.71; 95% CI, 0.56-0.91] for 2.5-3 g/day; and 3.5% [HR, 0.68; 95% CI, 0.49-0.92] for >3 g/day) on multivariable analysis. Conclusions The association between estimated sodium excretion and CV events was J-shaped. Compared with baseline sodium excretion of 4 to 5.99 g per day, sodium excretion of greater than 7 g per day was associated with an increased risk of all CV events, and a sodium excretion of less than 3 g per day was associated with increased risk of CV mortality and hospitalization for CHF. Higher estimated potassium excretion was associated with a reduced risk of stroke.
- Association Between Valvular Surgery and Mortality Among ... Context Heart failure (HF) is the most common complication of infective endocarditis. However, clinical characteristics of HF in patients with infective endocarditis, use of surgical therapy, and their associations with patient outcome are not well described. Objectives To determine the clinical, echocardiographic, and microbiological variables associated with HF in patients with definite infective endocarditis and to examine variables independently associated with in-hospital and 1-year mortality for patients with infective endocarditis and HF, including the use and association of surgery with outcome. Design, Setting, and Patients The International Collaboration on Endocarditis–Prospective Cohort Study, a prospective, multicenter study enrolling 4166 patients with definite native- or prosthetic-valve infective endocarditis from 61 centers in 28 countries between June 2000 and December 2006. Main Outcome Measures In-hospital and 1-year mortality. Results Of 4075 patients with infective endocarditis and known HF status enrolled, 1359 (33.4% [95% CI, 31.9%-34.8%]) had HF, and 906 (66.7% [95% CI, 64.2%-69.2%]) were classified as having New York Heart Association class III or IV symptom status. Within the subset with HF, 839 (61.7% [95% CI, 59.2%-64.3%]) underwent valvular surgery during the index hospitalization. In-hospital mortality was 29.7% (95% CI, 27.2%-32.1%) for the entire HF cohort, with lower mortality observed in patients undergoing valvular surgery compared with medical therapy alone (20.6% [95% CI, 17.9%-23.4%] vs 44.8% [95% CI, 40.4%-49.0%], respectively; P < .001). One-year mortality was 29.1% (95% CI, 26.0%-32.2%) in patients undergoing valvular surgery vs 58.4% (95% CI, 54.1%-62.6%) in those not undergoing surgery (P < .001). Cox proportional hazards modeling with propensity score adjustment for surgery showed that advanced age, diabetes mellitus, health care–associated infection, causative microorganism (Staphylococcus aureus or fungi), severe HF (New York Heart Association class III or IV), stroke, and paravalvular complications were independently associated with 1-year mortality, whereas valvular surgery during the initial hospitalization was associated with lower mortality. Conclusion In this cohort of patients with infective endocarditis complicated by HF, severity of HF was strongly associated with surgical therapy and subsequent mortality, whereas valvular surgery was associated with lower in-hospital and 1-year mortality.
- Incident Stroke and Mortality Associated With New-Onset A... Context New-onset atrial fibrillation (AF) has been reported in 6% to 20% of patients with severe sepsis. Chronic AF is a known risk factor for stroke and death, but the clinical significance of new-onset AF in the setting of severe sepsis is uncertain. Objective To determine the in-hospital stroke and in-hospital mortality risks associated with new-onset AF in patients with severe sepsis. Design and Setting Retrospective population-based cohort of California State Inpatient Database administrative claims data from nonfederal acute care hospitals for January 1 through December 31, 2007. Patients Data were available for 3 144 787 hospitalized adults. Severe sepsis (n = 49 082 [1.56%]) was defined by validated International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 995.92. New-onset AF was defined as AF that occurred during the hospital stay, after excluding AF cases present at admission. Main Outcome Measures A priori outcome measures were in-hospital ischemic stroke (ICD-9-CM codes 433, 434, or 436) and mortality. Results Patients with severe sepsis were a mean age of 69 (SD, 16) years and 48% were women. New-onset AF occurred in 5.9% of patients with severe sepsis vs 0.65% of patients without severe sepsis (multivariable-adjusted odds ratio [OR], 6.82; 95% CI, 6.54-7.11; P < .001). Severe sepsis was present in 14% of all new-onset AF in hospitalized adults. Compared with severe sepsis patients without new-onset AF, patients with new-onset AF during severe sepsis had greater risks of in-hospital stroke (75/2896 [2.6%] vs 306/46 186 [0.6%] strokes; adjusted OR, 2.70; 95% CI, 2.05-3.57; P < .001) and in-hospital mortality (1629 [56%] vs 18 027 [39%] deaths; adjusted relative risk, 1.07; 95% CI, 1.04-1.11; P < .001). Findings were robust across 2 definitions of severe sepsis, multiple methods of addressing confounding, and multiple sensitivity analyses. Conclusion Among patients with severe sepsis, patients with new-onset AF were at increased risk of in-hospital stroke and death compared with patients with no AF and patients with preexisting AF.
- Improving the Rules for Hospital Participation in Medicar...
BMJ Recent Articles
- Out of hours GPs' "culture of avoiding blame" is putting ... Out of hours GPs are afraid to admit mistakes and use the systems that have been designed to avoid a repeat of incidents because they fear they will be blamed when things go wrong, according to a new report by the NHS Alliance.The report follows a review of the work of 10 out of hours providers over the past year. It found that a “blame culture” and the “lack of a system that allows people to share information,” were putting patients in danger.The alliance is now in the process of developing a new anonymised system for out of hours GPs to share their mistakes, identify why things go wrong, and learn from each other.The system is set to include a website and teleconferencing system and will aim to highlight errors and to make sure that lessons are learnt for the future.The review also focused on the need to develop better...
- Should we treat lower urinary tract symptoms without a de... Lower urinary tract symptoms (LUTS) are common in the general population, their main causes (including overactive bladder and benign prostatic obstruction) are not life threatening, definitive diagnosis is invasive, and initial management is safe. Initial treatment of the symptoms without a definitive diagnosis is therefore sensible and avoids unnecessary secondary care.Defining the problemAround 1.8 billion men and women worldwide have LUTS, and the numbers are increasing rapidly as the population ages.1 The term was introduced in 1994 to escape the “prostate-centric” approach of doctors to lower urinary tract symptoms in men, which led to many men having unnecessary prostate surgery when their symptoms had other causes.2 Later, the International Continence Society divided symptoms into three categories: storage LUTS, including the symptoms of overactive bladder (urgency, urgency urinary incontinence, frequency, and nocturia) and stress urinary incontinence; voiding LUTS, including slow stream and hesitancy; and post-micturition LUTS, such as a feeling of...
- Should we treat lower urinary tract symptoms without a de... The term “lower urinary tract symptoms” (LUTS) was coined to cover the variety of symptoms that affect the bladder. The symptoms may be storage or emptying symptoms or both. It was initially introduced because of the potential difficulty with terms such as “prostatism,” which described bladder symptoms in older men that were thought to be due to prostatic enlargement. Unfortunately, the term has been extended to apply to any patient, male or female, young or old, with urinary symptoms. The other arguably misleading term that has come into common parlance is “overactive bladder.” Both these terms are non-specific, non-diagnostic descriptions of symptom complexes. Yet their widespread use can easily lead to treatment being decided without any knowledge of the underlying condition.From a clinical point of view, the term prostatism is more useful. Although it is also non-specific, it applied to a specific patient group—older men with prostatic enlargement with symptoms...
- Effectiveness of strategies incorporating training and su... Objective To assess the effectiveness of strategies incorporating training and support of traditional birth attendants on the outcomes of perinatal, neonatal, and maternal death in developing countries.Design Systematic review with meta-analysis.Data sources Medline, Embase, the Allied and Complementary Medicine database, British Nursing Index, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, BioMed Central, PsycINFO, Latin American and Caribbean Health Sciences Literature database, African Index Medicus, Web of Science, Reproductive Health Library, and Science Citation Index (from inception to April 2011), without language restrictions. Search terms were “birth attend*”, “traditional midwife”, “lay birth attendant”, “dais”, and “comadronas”. Review methods We selected randomised and non-randomised controlled studies with outcomes of perinatal, neonatal, and maternal mortality. Two independent reviewers undertook data extraction. We pooled relative risks separately for the randomised and non-randomised controlled studies, using a random effects model.Results We identified six cluster randomised controlled trials (n=138 549) and seven non-randomised controlled studies (n=72 225) that investigated strategies incorporating training and support of traditional birth attendants. All six randomised controlled trials found a reduction in adverse perinatal outcomes; our meta-analysis showed significant reductions in perinatal death (relative risk 0.76, 95% confidence interval 0.64 to 0.88, P<0.001; number needed to treat 35, 24 to 70) and neonatal death (0.79, 0.69 to 0.88, P<0.001; 98, 66 to 170). Meta-analysis of the non-randomised studies also showed a significant reduction in perinatal mortality (0.70, 0.57 to 0.84, p<0.001; 48, 32 to 96) and neonatal mortality (0.61, 0.48 to 0.75, P<0.001; 96, 65 to 168). Six studies reported on maternal mortality and our meta-analysis showed a non-significant reduction (three randomised trials, relative risk 0.79, 0.53 to 1.05, P=0.12; three non-randomised studies, 0.80, 0.44 to 1.15, P=0.26).Conclusion Perinatal and neonatal deaths are significantly reduced with strategies incorporating training and support of traditional birth attendants.
- How clinical and research failures lead to suboptimal pre... An evidence based or “rational” approach to prescribing is thought to maximise the benefit and minimise the harm from prescription drugs. Unfortunately, prescribing often does not meet this ideal despite clinicians’ best intentions. We use treatment of chronic tophaceous gout to show how apparently irrational prescribing arises from several interacting “failures” in both clinical practice and drug development.Treatment of chronic goutChronic tophaceous gout is the most common inflammatory arthritis in older men and affects about 1-2% of adults in the developed world.1 For most patients, allopurinol—a xanthine oxidase inhibitor that blocks the synthesis of uric acid—is highly effective in preventing recurrent attacks of acute gout and the development of chronic tophaceous gout.2 Allopurinol is easy to administer (generally requiring only a once daily dose), inexpensive, and generally well tolerated aside from the extremely rare, and sometimes predictable, allopurinol hypersensitivity reaction and other more common but generally minor or controllable adverse...
- Paralysed man asks High Court to allow doctors to end his... A 57 year old man who is almost totally paralysed with locked-in syndrome after a stroke is to seek a ruling from the High Court’s family division in London that doctors might lawfully give him a drug to end his life.The case, which was lodged with the court this week, follows another pending case in which a 42 year old man named only as Martin, also paralysed after a stroke, seeks the help of a palliative care doctor while he starves himself to death.In England and Wales, voluntary euthanasia is considered murder, carrying a mandatory life sentence, unless the person who does it can successfully plead diminished responsibility, which reduces it to manslaughter. Director of public prosecutions Keir Starmer said in guidance last year: “It is murder or manslaughter for a person to do an act that ends the life of another, even if he or she does so on...
- The placebo effect Varenicline is used as a smoking cessation aid. Its efficacy and safety were assessed by a double blind, placebo controlled, randomised controlled trial. In total, 213 participants were randomised to varenicline and 218 to placebo. Treatment was for 12 weeks, and participants were followed up for 14 weeks after treatment.1The primary end point was continuous abstinence from smoking for the final four weeks of treatment (weeks 9 to 12). The observed treatment effect—the rate of continuous abstinence—was 59% in the varenicline group and 39% in the placebo group. The difference between the varenicline and placebo treatment groups in continued absence between weeks 9 and 12 was significant (relative risk 1.6 (95% confidence interval 1.32 to 1.87); P<0.001).Which one of the following statements best quantifies the placebo effect?a) The observed treatment effect in the placebo group.b) The difference in observed treatment effect between the varenicline and placebo groups.c) The difference in...
- bmj;343/nov30_2/d7680/FIG1F1fig1This 57 year old smoker, with a history of high alcohol consumption and tonsillectomy, presented with pain in the left side of his throat. He had fetor with ulceration and leucoplakia in the left tonsillar fossa. The clinical impression was initially of oropharyngeal squamous cell carcinoma, and he received the appropriate investigations. But subsequent histology confirmed sarcoidosis and his symptoms were resolved with steroid treatment. Although biopsies are essential for persistent oropharyngeal lesions, any malignant histology must be confirmed early to avoid subjecting patients to unnecessary investigations and heightened anxiety.Patient consent obtained.
- After heart attacks, two types of drugs are commonly prescribed: antiplatelet treatment and selective serotonin reuptake inhibitors (SSRI) for depression. A retrospective analysis of patients discharged after acute myocardial infarction over 10 years found that compared with aspirin alone, the combined use of an SSRI and antiplatelet therapy resulted in a higher risk of bleeding. The combination of two antiplatelet agents plus SSRI also increased the risk of bleeding compared with dual antiplatelet therapy alone (CMAJ 2011;183:1835-43, doi:10.1503/cmaj.100912). Cemented or cementless; apparently, it doesn’t matter in knees. A cohort of 52 patients who underwent simultaneous bilateral total knee replacement with identical prostheses—one cemented, the other non-cemented—were followed up for an average of 13.6 years. At the final review there were no significant differences between the groups in mean Knee Society scores, osteoarthritis indices, ranges of knee movement, patient satisfaction, or radiological results. Survival rates of the femoral components were 100%...
- How attractive is the NHS to private providers? The Health and Social Care Bill sets out a landscape that has few boundaries for private sector involvement. In a speech this September, the English health minister Earl Howe said there are “huge opportunities” for the private sector within the current health service reforms.1 To critics this was the articulation of their long held fears: that the reforms are little more than privatisation by the back door. But what is mere rhetoric and what is fact? What is the current extent of the role of the private sector and is this set to expand rapidly and irreversibly as critics maintain? “People have simply not appreciated the magnitude of the changes the bill proposes,” says Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine. “There is nothing in the bill to stop the entirety of NHS services being provided by private sector firms in...
The Lancet
- [This Week in Medicine] November 26–December 2, 2011 Geron Corporation is to shelve its stem cell programme, including an ongoing clinical trial, after a strategic review of costs, timelines, and assets. It plans instead to focus on the advancement of its two cancer drug candidates—imetelstat and GRN1005—through phase 2 clinical trials. More than a third of the workforce will be axed.
- [Editorial] Climate and health in a post-Kyoto world Next week, delegations from 194 countries will meet in Durban, South Africa, at the 17th Conference of the Parties (COP17) to the UN Framework Convention on Climate Change (Nov 28–Dec 9) to discuss the all important successor to the 1997 Kyoto Protocol, which expires in 2012. It will be a historic, make-or-break meeting on climate change. And, importantly, it will host the largest health presence at a COP meeting to date. At least 12 health side-events will take place, including a climate and health summit led by non-governmental organisations and a high-level round table on implementation of the African regional framework for health adaptation.
- [Editorial] Cardiovascular health advice for children in ... 83 million Americans had cardiovascular disease in 2010, and some 800 000 died from the disease. Avoidance of risk factors such as smoking, poor diet, and sedentary behaviour is vital to reducing these numbers, but how early can lifestyle changes be meaningfully adopted? New guidelines from the US National Heart, Lung, and Blood Institute (NHLBI) suggest it is never too soon to start. In their comprehensive report, an expert panel tracked how eight key risk factors for atherosclerosis in childhood translated into cardiovascular disease in adults.
- [Editorial] Taking sex into account in medicine Throughout Europe, despite women often forming the majority of students at university, fewer women than men are appointed to high-level jobs in medicine and science. Evidence presented at the first European Gender Summit in Brussels (Nov 8–9) illustrates that without targets or quotas, it will take decades, maybe centuries, to reach equality at the top. Female role models, mentors, and family friendly employment policies encourage and allow women to aim high. Moreover, gender-diverse teams have higher team IQs and promote innovation.
- [Comment] SCIPIO brings new momentum to cardiac cell therapy The human heart is a dynamic organ, not only in constant motion but also, contrary to the traditional notion of a post-mitotic organ without the potential for self-renewal, capable of regeneration and repair from endogenous and exogenous stem cells. 10 years ago Orlic and colleagues first reported the repair of infarcted myocardium through transplantation of bone marrow cells in mice. Only weeks later, Strauer and colleagues bravely (some say ruthlessly) injected autologous bone marrow cells intracoronarily in a patient with a 6-day-old myocardial infarction, who experienced a reduction in infarct size and an increase in ejection fraction over the next 10 weeks.
- [Comment] Intensified chemotherapy for diffuse large B-ce... In The Lancet, Christian Récher and colleagues report the findings of their randomised trial of dose-intense chemotherapy with rituximab, doxorubicin, cyclophosphamide, vindesine, bleomycin, and prednisone (R-ACVBP) versus rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). 379 patients aged 18–59 years with diffuse large B-cell lymphoma and an age-adjusted International Prognostic Index of 1 were randomly assigned to receive either dose-intense chemotherapy with four cycles of R-ACVBP with a subsequent sequential consolidation with two cycles of methotrexate and calcium folinate rescue, four cycles of rituximab with etoposide and ifosfamide, and two cycles of cytarabine or to receive eight cycles of R-CHOP at intervals of 21 days.
- [Comment] Prevention of cervical cancer in women's hands:... In The Lancet, Eduardo Lazcano-Ponce and colleagues report the results of the first community-based randomised trial to compare the effectiveness of HPV DNA testing of vaginal samples self-collected at home with clinician-collected cervical cytology, for detection of prevalent cervical intraepithelial neoplasia (CIN) grade 2 or greater. The trial randomly assigned 20 256 Mexican women aged between 25 and 65 years of low socioeconomic status to self-collection of samples for HPV testing (n=9202) or to clinican-collected cervical cytology (n=11 054).
- [Comment] Rabbit ATG for aplastic anaemia treatment: a ba... Advances in medical care and research invariably result in improved outcomes for patients over time. Aplastic anaemia is a rare but serious form of bone-marrow failure that results in severe pancytopenia, a high risk of life-threatening infection, and haemorrhage. Over the past five decades, survival of patients has improved from around 25% to 60–80%, as allogeneic bone-marrow transplantation or immunosuppressive therapy have become available. However, a recent change in the availability of immunosuppressive therapy drugs has had a negative impact on patients' outcome.
- [Comment] Assessment of syndromic surveillance in Europe Potential public health threats are generally detected through specific surveillance systems based on predetermined diseases and rapid biological confirmation. However, such systems are not rapid and they do not detect all health hazards, especially unexpected threats. Syndromic surveillance can support public health professionals in this endeavour.
- [Comment] Evidence-based medicine comes to Gaza In February, 2011, an Evidence-Based Medicine (EBM) Unit was established at the medical school of the Islamic University, Gaza, to promote EBM in medical schools in Gaza and throughout the Gaza Strip (). Gaza needs EBM for the same reasons that it is needed elsewhere: to improve people's health through evidence-based decisions that improve their lifespan and quality of life.
Listen to The Lancet
- Listen to The Lancet: 17 November New data and discussion about adolescents and self-harm.
- Listen to The Lancet: 11 November Discussion of the global burden of influenza on children under 5 years of age and its impact on pneumonia incidence.
- Listen to The Lancet: 3 November Padraig Warde discusses the value of radiotherapy in addition to hormone therapy in the treatment of locally advanced prostate cancer.
- Listen to The Lancet: 28 October Discussion of the CAPP2 study, a randomised trial investigating whether aspirin can reduce the risk of familial colorectal cancer.
- Listen to The Lancet: 17 October Discussion of a new Series on Global Mental Health.
- Listen to The Lancet: 14 October Bill Summerskill with an overview of journal content in the surgery themed issue.
- Listen to The Lancet: 07 October Sharmila Devi discusses the situation in Bahrain, where health professionals have been arrested for aiding protesters earlier this year.
- Listen to The Lancet: 30 September Discussion of a potential new approach for more effective management of lower back pain in primary care.
- Listen to The Lancet: 23 September Patrice Engle discusses a new series on Child Development.
- Listen to The Lancet: 9 September Sabine Kleinert reviews a new three-part clinical Series on COPD.
Archives of Internal Medicine current issue
- Reconsidering Transfer for Percutaneous Coronary Interven...
- Factors Associated With 30-Day Readmission Rates After Pe... Background Thirty-day readmission rates have become a publicly reported quality performance measure for congestive heart failure, acute myocardial infarction, and percutaneous coronary intervention (PCI). However, little is known regarding the factors associated with 30-day readmission after PCI. Methods To assess the demographic, clinical, and procedural factors associated with 30-day readmission rates after PCI, we identified 15 498 PCI hospitalizations (elective or for acute coronary syndromes) from January 1998 through June 2008 at Saint Marys Hospital, Rochester, Minnesota. All were included in this analysis. Multivariate logistic regression models were used to estimate the adjusted association between demographic, clinical, and procedural variables and 30-day readmission. The association between 30-day readmission and 1-year mortality was estimated using Cox proportional hazards models with readmission as a time-dependent covariate and by using landmark analysis. The main outcome measures were all-cause 30-day readmission to any hospital following PCI and 1-year mortality. Results Overall, 9.4% of PCIs (n = 1459) were readmitted, and 0.68% of PCIs (n = 106) resulted in death within 30 days after discharge. After multivariate analysis, female sex, Medicare insurance, having less than a high school education, unstable angina, cerebrovascular accident or transient ischemic attack, moderate to severe renal disease, chronic obstructive pulmonary disease, peptic ulcer disease, metastatic cancer, and a length of stay of more than 3 days were associated with an increased risk of 30-day readmission after PCI. Thirty-day readmission after PCI was associated with a higher risk of 1-year mortality (adjusted hazard ratio, 1.38; 95% CI, 1.08-1.75; P = .009). Conclusions Nearly 1 in 10 patients undergoing PCI were readmitted within 30 days. Thirty-day readmission after PCI was associated with a higher risk of 1-year mortality.
- Prediction Is Very Hard, Especially About the Future: Can...
- Improvement in Revascularization Time After Creation of a...
- Frequent Fracture of TrapEase Inferior Vena Cava Filters:...
- Invited Commentary--Implantable Cardioverter/Defibrillato...
- Cognitive Behavior Therapy, Exercise, or Both for Treatin... Background The clinical impact of telephone-delivered cognitive behavioral therapy (TCBT), exercise, or a combined intervention in primary care patients with chronic widespread pain (CWP) is unclear. Methods A total of 442 patients with CWP (meeting the American College of Rheumatology criteria) were randomized to receive 6 months of TCBT, graded exercise, combined intervention, or treatment as usual (TAU). The primary outcome, using a 7-point patient global assessment scale of change in health since trial enrollment (range: very much worse to very much better), was assessed at baseline and 6 months (intervention end) and 9 months after randomization. A positive outcome was defined as "much better" or "very much better." Data were analyzed using logistic regression according to the intention-to-treat principle. Results The percentages reporting a positive outcome at 6 and 9 months, respectively, were TAU group, 8% and 8%; TCBT group, 30% and 33%; exercise group, 35% and 24%; and combined intervention group, 37% and 37% (P < .001). After adjustment for age, sex, center, and baseline predictors of outcome, active interventions improved outcome compared with TAU: TCBT (6 months: odds ratio [OR], 5.0 [95% CI, 2.0-12.5]; 9 months: OR, 5.4 [95% CI, 2.3-12.8]), exercise (6 months: OR, 6.1 [95% CI, 2.5-15.1]; 9 months: OR, 3.6 [95% CI, 1.5-8.5]), and combined intervention (6 months: OR, 7.1 [95% CI, 2.9-17.2]; 9 months: OR, 6.2 [95% CI, 2.7-14.4]). At 6 and 9 months, combined intervention was associated with improvements in the 36-Item Short Form Health Questionnaire physical component score and a reduction in passive coping strategies. Conclusions on cost-effectiveness were sensitive to missing data. Conclusion TCBT was associated with substantial, statistically significant, and sustained improvements in patient global assessment. Trial Registration clinicaltrials.gov Identifier: ISRCTN67013851
- Thinking Our Way to Better Treatments of Chronic Pain [Ed...
- Invited Commentary--Balancing Transparency and Uncertaint...
- Invited Commentary--Early Signals of Harmful Drugs: Comme...
Annals of Internal Medicine current issue
- Warfarin Dose Assessment Every 4 Weeks Versus Every 12 We... Background: Guidelines recommend that patients receiving warfarin undergo international normalized ratio (INR) monitoring every 4 weeks. Objective: To investigate whether assessment of warfarin dosing every 12 weeks is as safe as assessment every 4 weeks. Design: Noninferiority randomized trial. The randomization schedule (in a 1:1 ratio) was computer-generated, and allocation was concealed until the database was locked by using a centralized schedule. Patients, study and clinical personnel, adjudicators of clinical events, and the study statistician were blinded to treatment assignment. (ClinicalTrials.gov registration number: NCT00356759) Setting: Single center in Hamilton, Ontario, Canada. Patients: 250 patients receiving long-term warfarin therapy, whose dose was unchanged for at least 6 months; 226 completed the study. Intervention: Dosing assessment every 12 weeks (n = 124) compared with every 4 weeks (n = 126) for 12 months. Patients in the 12-week group were tested every 4 weeks; sham INRs within the target range were reported for two of the three 4-week periods. Measurements: Percentage of time in the therapeutic range (primary outcome) and number of extreme INRs, changes in maintenance dose, major bleeding events, objectively verified thromboembolism, and death (secondary outcomes). Results: The percentage of time in the therapeutic range was 74.1% (SD, 18.8%) in the 4-week group compared with 71.6% (SD, 20.0%) in the 12-week group (absolute difference, 2.5 percentage points [1-sided 97.5% upper confidence bound, 7.3 percentage points]; noninferiority P = 0.020 for a 7.5–percentage point margin). Fewer patients in the 12-week group than in the 4-week group had any dose changes (37.1% vs. 55.6%; absolute difference, 18.5 percentage points [95% CI, 6.1 to 30.0 percentage points]; P = 0.004). Secondary outcomes did not differ between groups. Limitations: Patients in the 12-week group had testing and contact with clinic staff every 4 weeks. The study was conducted at a single center and used surrogate outcomes. Conclusion: Assessment of warfarin dosing every 12 weeks seems to be safe and noninferior to assessment every 4 weeks. A comparison of INR testing, patient contact, and warfarin dose assessment every 12 weeks versus every 4 weeks is necessary before INR testing every 12 weeks can be routinely recommended for practice. Primary Funding Source: Physicians' Services Incorporated Foundation.
- Risks for Stroke, Bleeding, and Death in Patients With At... Background: CHADS2 is a simple, validated risk score for predicting the risk for stroke in patients with atrial fibrillation not treated with anticoagulants. There are sparse data on the risk for thrombotic and bleeding complications according to the CHADS2 score in patients receiving anticoagulant therapy. Objective: To evaluate the prognostic importance of CHADS2 risk score in patients with atrial fibrillation receiving oral anticoagulants, including the vitamin K antagonist warfarin and the direct thrombin inhibitor dabigatran. Design: Subgroup analysis of a randomized, controlled trial. (ClinicalTrials.gov registration number: NCT00262600) Setting: Multinational study setting. Patients: 18 112 patients with atrial fibrillation who were receiving oral anticoagulants. Measurements: Baseline CHADS2 score, which assigns 1 point each for congestive heart failure, hypertension, age 75 years or older, and diabetes mellitus and 2 points for stroke. Results: Distribution of CHADS2 scores were as follows: 0 to 1—5775 patients; 2—6455 patients; and 3 to 6—5882 patients. Annual rates of the primary outcome of stroke or systemic embolism among all participants were 0.93% in patients with a CHADS2 score of 0 to 1, 1.22% in those with a score of 2, and 2.24% in those with a score of 3 to 6. Annual rates of other outcomes among all participants with CHADS2 scores of 0 to 1, 2, and 3 to 6, respectively, were the following: major bleeding, 2.26%, 3.11%, and 4.42%; intracranial bleeding, 0.31%, 0.40%, and 0.61%; and vascular mortality, 1.35%, 2.39%, and 3.68% (P < 0.001 for all comparisons). Rates of stroke or systemic embolism, major and intracranial bleeding, and vascular and total mortality each increased in the warfarin and dabigatran groups as CHADS2 score increased. The rates of stroke or systemic embolism with dabigatran, 150 mg twice daily, and of intracranial bleeding with dabigatran, 150 mg or 110 mg twice daily, were lower than those with warfarin; there was no significant heterogeneity in subgroups defined by CHADS2 scores. Limitation: These analyses were not prespecified and should be deemed exploratory. Conclusion: Higher CHADS2 scores were associated with increased risks for stroke or systemic embolism, bleeding, and death in patients with atrial fibrillation receiving oral anticoagulants. Primary Funding Source: Boehringer Ingelheim.
- Effect of 12 Months of Whole-Body Vibration Therapy on Bo... Background: Although data from studies in animals demonstrated beneficial effects of whole-body vibration (WBV) therapy on bone, clinical trials in postmenopausal women showed conflicting results. Objective: To determine whether WBV improves bone density and structure. Design: A 12-month, single-center, superiority, randomized, controlled trial with 3 parallel groups. (ClinicalTrials.gov registration number: NCT00420940) Setting: Toronto General Hospital, Ontario, Canada. Participants: 202 healthy postmenopausal women with bone mineral density (BMD) T-scores between –1.0 and –2.5 who were not receiving prescription bone medications. Intervention: Participants were randomly assigned to 1 of 3 groups (1:1:1 ratio) by using a block-randomization scheme and sealed envelopes. They were asked to stand on a low-magnitude (0.3g) 90-Hz or 30-Hz WBV platform for 20 minutes daily or to serve as control participants; all participants received calcium and vitamin D. Measurements: Bone outcome assessors, who were blinded to group assignment, determined trabecular volumetric BMD and other measurements of the distal tibia and distal radius with high-resolution peripheral quantitative computed tomography and areal BMD with dual-energy x-ray absorptiometry at baseline and at 12 months. Results: 12 months of WBV therapy had no significant effect on any bone outcomes compared with no WBV therapy. For the primary outcome of tibial trabecular volumetric BMD, mean change from baseline was 0.4 mg/cm3 (95% CI, –0.4 to 1.2 mg/cm3) in the 90-Hz WBV group, –0.1 mg/cm3 (CI, –1.0 to 0.8 mg/cm3) in the 30-Hz WBV group, and –0.2 mg/cm3 (CI, –1.1 to 0.6 mg/cm3) in the control group (P = 0.55). Changes in areal BMD at the femoral neck, total hip, and lumbar spine were also similar among the groups. Overall, low-magnitude WBV at both 90 and 30 Hz was well-tolerated. Limitations: Adherence to WBV ranged from 65% to 79%. Double-blinding was not possible. Conclusion: Whole-body vibration therapy at 0.3g and 90 or 30 Hz for 12 months did not alter BMD or bone structure in postmenopausal women who received calcium and vitamin D supplementation. Primary Funding Source: Physicians' Services Incorporated Foundation.
- Whole-Body Vibration Therapy for Osteoporosis: State of t... Clinical guidelines for osteoporosis recommend dietary and pharmacologic interventions and weight-bearing exercise to prevent bone fractures. These interventions sometimes have low adherence and can cause adverse effects. A proposed alternative or adjunctive treatment is whole-body vibration therapy (WBV), in which energy produced by a forced oscillation is transferred to an individual from a mechanical vibration platform. Whole-body vibration platforms are not approved by the U.S. Food and Drug Administration for medical purposes. This review provides a broad overview of important issues related to WBV therapy for prevention and treatment of osteoporosis. Relying on key informants and a search of the gray and published literature from January 2000 to August 2011, the investigators found that the designs of WBV platforms and protocols for their use vary widely. The optimal target population for the therapy is not defined. Although WBV has some theoretical advantages, key informants have voiced several concerns, including uncertain safety and potential consumer confusion between low-intensity vibration platforms intended for osteoporosis therapy and high-intensity platforms intended for exercise. Finally, the scant literature did not establish whether WBV therapy leads to clinically important increases in bone mineral density or reduces risk for fracture.
- Liquid-Based Cytology and Human Papillomavirus Testing to... This article has been corrected. For original version, click "Original Version (PDF)" in column 2. Background: Screening programs using conventional cytology have successfully reduced cervical cancer, but newer tests might enhance screening. Purpose: To systematically review the evidence on liquid-based cytology (LBC) and high-risk human papillomavirus (HPV) screening for U.S. Preventive Services Task Force use in updating its 2003 recommendation. Data Sources: MEDLINE, Cochrane Central Register of Controlled Trials, and PsycINFO from January 2000 through September 2010. Study Selection: Two independent reviewers selected fair- to good-quality English-language studies that compared LBC or HPV-enhanced primary screening with conventional cytology in countries with developed population-based screening for cervical cancer. Data Extraction: At least 2 independent reviewers critically appraised and rated the quality of studies and used standardized abstraction forms to extract data about test performance for detecting cervical intraepithelial neoplasia (CIN) and cancer and screening-related harms. Data Synthesis: On the basis of 4 fair- to good-quality studies (141 566 participants), LBC had equivalent sensitivity and specificity to conventional cytology. Six fair- to good-quality diagnostic accuracy studies showed that 1-time HPV screening was more sensitive than cytology for detecting CIN3+/CIN2+ but was less specific. On the basis of 2 fair- to good-quality randomized, controlled trials (RCTs) (120 533 participants), primary HPV screening detected more cases of CIN3 or cancer in women older than 30 years. Four fair- to good-quality diagnostic accuracy studies and 4 fair- to good-quality RCTs showed mixed results of cotesting (HPV plus cytology) in women aged 30 years or older compared with cytology alone, with no clear advantage over primary HPV screening. Incomplete reporting of results for all screening rounds, including detection of disease and colposcopies, limits our ability to determine the net benefit of HPV-enhanced testing strategies. Limitation: Resources were insufficient to gather unpublished data, short-term trial data showed possible ascertainment bias, and most RCTs used protocols that differed from current U.S. practice. Conclusion: Evidence supports the use of LBC or conventional cytology for cervical cancer screening, but more complete evidence is needed before HPV-enhanced primary screening is widely adopted for women aged 30 years or older. Primary Funding Source: Agency for Healthcare Research and Quality.
- Risk Factors and Other Epidemiologic Considerations for C... Despite the success of cervical cancer screening programs, questions remain about the appropriate time to begin and end screening. This review explores epidemiologic and contextual data on cervical cancer screening to inform decisions about when screening should begin and end. Cervical cancer is rare among women younger than 20 years. Screening for cervical cancer in this age group is complicated by lower rates of detection and higher rates of false-positive results than in older women. Methods used to diagnose and treat cervical intraepithelial neoplasia have important potential adverse effects. High-risk human papillomavirus infections and abnormalities on cytologic and histologic examination have relatively high rates of regression. Accordingly, cervical cancer screening in women younger than 20 years may be harmful. The incidence of, and mortality rates from, cervical cancer and the proportion of U.S. women aged 65 years or older who have had a Papanicolaou smear within 3 years have decreased since 2000. Available evidence supports discontinuation of cervical cancer screening among women aged 65 years or older who have had adequate screening and are not otherwise at high risk. Further reductions in the burden of cervical cancer in older women are probably best achieved by focusing on screening those who have not been adequately screened.
- Promises and Challenges of Stem Cell Research for Regener... In recent years, stem cells have generated increasing excitement, with frequent claims that they are revolutionizing medicine. For those not directly involved in stem cell research, however, it can be difficult to separate fact from fiction or realistic expectation from wishful thinking. This article aims to provide internists with a clear and concise introduction to the field. While recounting some scientific and medical milestones, the authors discuss the 3 main varieties of stem cells—adult, embryonic, and induced pluripotent—comparing their advantages and disadvantages for clinical medicine. The authors have sought to avoid the moral and political debates surrounding stem cell research, focusing instead on scientific and medical issues.
- Learning the Respective Roles of Warfarin and Dabigatran ...
- A Matter of the Heart
- House Call
Annals of Internal Medicine Podcast
- Issue Summary for November 15, 2011 Summary of the November 15, 2011 issue featuring information on screening for hepatitis C virus infection, anticoagulation, whole body vibration therapy, screening for cervical cancer, and stem cell research.
- Issue Summary for November 1, 2011 Summary of the November 1, 2011 issue of Annals of Internal Medicine featuring research on yoga and back pain, dual antiplatelet therapy, implanted cardiac devices and airport security screening, and oncologists' communication skills; reviews on stress loaded MRI, a clinical practice guideline on VTE prophylaxis, and a discussion of the ethics of retainer practices in medicine.
- Issue Summary for October 18, 2011 Summary of the October 18, 2011 issue of Annals of Internal Medicine including early release articles related to the US Preventive Services Task Force recommendations on screening for prostate cancer and cervical cancer.
- Issue Summary for October 4, 2011 Summary of the October 4, 2011 issue of Annals of Internal Medicine: Original research reports address pericarditis, safety of MRI in patients with implanted cardiac devices, and Takayatsu arteritis. The issue also includes reviews of obesity treatments and pulmonary embolism diagnosis, commentaries on medical education funding in the US and care commissioning in the United Kingdom, two On Being a Doctor essays, and an In the Clinic review of management of new HIV infection.
- Issue Summary for September 20, 2011 Summary of the September 20, 2011 issue of Annals of Internal Medicine: Among the topics covered in this issue are pharyngitis, myocardial infarction,health effects of BP, electrocardiography, and residency training. An early release guideline of transient loss of consciousness is also discussed.
- Issue Summary for September 6, 2011 Summary of the September 6, 2011 issue of Annals of Internal Medicine: Original research reports address transfusion safety, bariatric surgery, type 2 diabetes, and cognitive impairment. The issue also includes a review on quality of care during housestaff changeover, an exploration of informed consent, two Ideas and Opinions commentary, two On Being a Doctor essays, and an In the Clinic review of sickle cell anemia.
- Issue Summary for August 16, 2011 Summary of the August 16, 2011 issue of Annals of Internal Medicine. Original research reports address HIV therapy in Africa, herbal therapy for influenza, and hip fracture outcomes. The issue also includes a comparative effectiveness review on pain management after hip fracture, a commentary on the need to inform patients about hospital performance when referring them for care, a clinical guideline on bladder cancer screening and another on heart failure, two On Being a Doctor essays, and ACP Journal Club.
- Issue Summary for August 2, 2011 Summary of this issue's articles; Original research reports address transthoracic needle biopsy, syphilis, hospitalist care, and omega 3 fatty acids. The issue also includes a comparative effectiveness review of radiation therapy for localized prostate cancer, a clinical guideline on chronic obstructive pulmonary disease, two On Being a Doctor essays, and an In the Clinic review on psoriasis.
- Issue Summary for July 19, 2011 Summary of this issue's articles; including a systematic review on the "July Effect", identifying families with Lynch syndrome and colorectal cancer, the effect of location on COPD mortality, a study of how the presentation of drug therapy risks and benefits affects lay people's comprehension, a systematic review of how low-health literacy affects health outcomes, a review of after-hours primary care in the Netherlands, a review discussing reprogramming cells to enter an embryonic, stem-cell like state, and the potential advantages for regenerative and reproductive medicine, including an exploration of associated medical, moral, and political hurdles, an ideas and opinions article addressing compassionate release and overcrowded prisons, twelve new article reviews in the Journal Club section, and this issue's On Being a Doctor.
- Issue Summary for July 5, 2011 Summary of this issue's articles; including studies on low back pain, timing of breast cancer screening, long-term risk of cardiovascular disease in hematopoietic stem-cell transplant recipients, pocket-sized portable echocardiogram devices, sources of bias in comparative effectiveness research, an update on women's health, and this month's In The Clinic on osteoporosis.
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...
- The intuitive appeal of case series thinking: a challenge... Time pressures often require highly efficient, intuitive approaches to decision making. On the fly, we depend upon short cuts, or heuristics, to make rapid, efficient decisions. Heuristics are indispensable cognitive processes for quickly solving problems without the formal use of logic and research evidence. Encountering unfamiliar situations, for example, we act based on outcomes of recent similar, memorable or noteworthy experiences (the availability heuristic).1 In light of the flood of data encountered in daily life, such short cuts are unavoidable, but they can also lead to error, such as overestimating the likelihood of a rare event. Physicians, like everybody else, are psychologically predisposed to similar errors in their medical practices.2 Evidence-based practice and teaching requires an awareness of the potential pitfalls of intuitive, heuristically derived clinical decision making and effective strategies for circumventing these pitfalls. The availability heuristic implies that our personal clinical experiences will...
- A qualitative approach to Bayes' theorem While decisions made according to Bayes' theorem are the academic normative standard, the theorem is rarely used explicitly in clinical practice. Yet the principles can be followed without intimidating mathematics. To do so, one can first categorise the prior-probability of the disease being tested for as very unlikely (less likely than 10%), unlikely (10–33%), uncertain (34–66%), likely (67–90%) or very likely (more likely than 90%). Usually, for disorders that are very unlikely or very likely, no further testing is needed. If the prior probability is unlikely, uncertain or likely, a test and a Bayesian-inspired update process incorporating the result can help. A positive result of a good test increases the probability of the disorder by one likelihood category (eg, from uncertain to likely) and a negative test decreases the probability by one category. If testing is needed to escape the extremes of likelihood (eg, a very unlikely but particularly dangerous condition or in the circumstance of population screening, or a very likely condition with a particularly noxious treatment), two tests may be needed to achieve. Negative results of tests with sensitivity ≥99% are sufficient to rule-out a diagnosis; positive results of tests with specificity ≥99% are sufficient to rule-in a diagnosis. This method overcomes some common heuristic errors: ignoring the base rate, probability adjustment errors and order effects. The simplicity of the method, while still adhering to the basic principles of Bayes' theorem, has the potential to increase its application in clinical practice.
- Older women who use bisphosphonate for longer than 5 year... Context It is now recognised that fractures of the subtrochanteric femur or femoral shaft (ST/FS fractures) can be divided radiologically into (1) typical fractures and (2) atypical fractures. The latter appear to be rare in patients untreated by bisphosphonates. In this new study, Park-Wyllie et al used Ontario claims data to investigate the association between the amount of bisphosphonates taken and the risk of ST/FS fractures. Methods The study was a nested 5:1 case-control study, linking prescriptions with hospitalisations, physician service claims and death certificates. Women aged 68 years or older who filled prescriptions for bisphosphonates at least once over a 6-year period were included. Those with malignant disease in the past 10 years, specific bone diseases or secondary causes of osteoporosis (past 5 years) and osteoporosis treatment in the past year were excluded, providing 205 466 women for study. Cases were defined as first ST/FS...
- People aged above 65 treated for latent tuberculosis are ... Context Treatment of latent tuberculosis infection (LTBI) is an important tuberculosis prevention and control strategy, especially in high-resource countries. The effectiveness of LTBI treatment, which usually consists of isoniazid (also known as isonicotinylhydrazine (INH)) for 6–9 months, is limited by poor patient adherence because of long treatment duration and adverse effects. The most common serious adverse effect of INH is hepatotoxicity, which increases with age and can be fatal.1 A meta-analysis of six studies found that the pooled rate of INH-associated hepatotoxicity was 0.6%.2 Methods Smith and colleagues conducted a population-based evaluation of serious adverse events of LTBI treatment in Quebec, Canada. Data were abstracted from administrative databases of the government managed-care health insurer (covers more than 99% of permanent residents). The authors compared an LTBI treatment cohort consisting of persons in the health insurance database who received either isoniazid or rifampin...
- Exposure to diagnostic radiation and risk of childhood ca... Context An association between in utero exposure to ionising radiation and childhood cancer, in particular leukaemia, was first identified in 1956.1 Subsequent studies have reported similar findings.2 3 To date, all have retrospectively interviewed mothers regarding exposure to diagnostic radiation and are therefore susceptible to recall bias. Little is known about the effects of neonatal exposure to diagnostic radiation. The purpose of this study was to determine whether exposure to diagnostic radiation and ultrasound in utero and during the first 100 days of life is associated with childhood cancer. Methods A case-control study was chosen as childhood cancer is relatively rare in the UK, affecting 138.6 per million children under 14 years.4 Cases were identified from the UK Childhood Cancer Study (UKCCS), a large multicentre study of childhood cancer. For each case, two controls matched for...
- Automated blood pressure readings in primary care demonst... Context Despite the use of gold standard equipment such as mercury sphygmomanometers in primary care for the measurement of blood pressure, accuracy remains a problem. This is due to a combination of system (eg, lack of calibration of instruments), physician (eg, observer error) and patient (eg, sympathetic drive) factors. Programmable automatic and semiautomatic oscillometric devices are likely to replace such devices because of occupational health concerns with the use of mercury. Methods This is a cluster randomised controlled study of an automated oscillometric blood pressure device method of determining blood pressure (intervention) versus usual manual measurement (control) in primary care. Both arms ambulatory blood pressure (ABP) measurements were also taken. The study included 555 patients with systolic hypertension (treated and untreated) and no serious comorbidities under the care of 88 primary care physicians in 67 Canadian primary care practices. The intervention was an automated oscillometric blood...
- Two sputum samples at once for diagnosis of tuberculosis ... Context Tuberculosis (TB) persists as a major cause of human morbidity and mortality, affecting almost 9.4 million people and causing 1.8 million deaths yearly worldwide.1 Examining Mycobacterium tuberculosis bacilli, using light microscopy with Ziehl–Neelsen stain, is still considered the most specific, cost-effective, quick and reliable test for the diagnosis of pulmonary TB.2 In recent years, new diagnostics such as ‘Xpert MTB/RIF’ (97.6% sensitivity and 99.2% specificity) have emerged and are being endorsed by the WHO. The ‘Gene Xpert’ has been recommended by WHO to use as a first-line test for multidrug-resistant TB or HIV-associated TB.3 Collecting and processing quality sputum specimens for microscopy is a manageable process but requires trained and dedicated laboratory staff and motivated patients. In reality, most of the peripheral laboratories in high TB burden countries often face understaffing, lack of time, skills and resources to carry out sputum...
- A single Xpert MTB/RIF test of sputum for diagnosis of tu... Context In 2009, there were more than 9 million new cases of tuberculosis, but only 63% were diagnosed. The situation for multidrug-resistant tuberculosis (MDR-TB) was even more dismal, with less than 12% of the estimated 250 000 cases diagnosed.1 The most important cause for the diagnostic gap was the absence of a rapid and sensitive test. Smear microscopy, the most widespread first-line diagnostic, is cheap and simple but has poor sensitivity and cannot detect resistance. Culture is highly sensitive and can identify drug resistance, but it requires a sophisticated laboratory infrastructure and is slow. Following a large evaluation study,2 the WHO recommended Xpert MTB/RIF (Xpert), a highly automated real-time PCR assay, as the initial diagnostic test for people suspected of HIV-associated tuberculosis or MDR-TB.3 Methods Boehme and colleagues performed a large prospective implementation study comparing patients for whom Xpert results...
- Physicians' calling patients on excess weight may provide... Context Recent estimates suggest that approximately two-thirds of Americans are overweight and one-third are obese.1 The current study evaluated patients' perceptions of overweight and obesity in a nationally representative sample of adults in the USA and examined whether reports of physician acknowledgement of patients' weight status are associated with a difference in their perceptions and behaviours. Methods The participants included in this study are participants in the 2005–2008 National Health and Nutrition Examination Survey study, aged between 20 and 64 years with measured body mass index (BMI), who were asked whether they had been told by their physician or another health professional that they were overweight. There were 7790 participants, of whom 5474 had a BMI of 25.0 or greater including 2874 with a BMI of 30.0 or greater. The main outcome measure was the proportion of participants who considered themselves as ‘not overweight’...
Cleveland Clinic Journal of Medicine current issue
- Quality, frailty, and common sense
- The negative U wave in the setting of demand ischemia (AU...
- Dabigatran (OCTOBER 2011)
- Correction
- A 25-year-old man with very high alkaline phosphatase
- A less common source of dyspnea in scleroderma
- Presumed premature ventricular contractions
- A 54-year-old woman with pancytopenia
- Essential tremor: Choosing the right management plan for ... Essential tremor is a common neurologic problem seen widely at all levels of patient care. It should be differentiated from secondary causes of tremor and Parkinson disease. It can be managed with commonly used drugs. However, severe, resistant, or atypical cases should be referred to a specialist for evaluation and the possible use of botulinum toxin or deep brain stimulation.
- Bioidentical hormone therapy: Clarifying the misconceptions Many women are turning to bioidentical hormone therapy on the basis of misconceptions and unfounded claims, eg, that this therapy can reverse the aging process and that it is more natural and safe than approved hormone therapy. The aim of this article is to clarify some of the misconceptions.
QJM - current issue
- Is uric acid good for you?
- Is there anything good in uric acid? High uric acid (UA) levels can cause gout, urolithiasis and acute and chronic nephropathy, all of which are due to the deposit of urate crystals. There is also increasing evidence of relationships of hyperuricemia with other important disorders, including hypertension, chronic renal disease, metabolic syndrome and cardiovascular disease, as well as an increased mortality, although a causal relationship between these conditions has not been clearly established. On the other hand, low UA levels are not known to cause any disorder or disease. However, in the last few years a higher prevalence and progression of some neurological diseases have been associated with a low UA, and it is possible that they may predispose to some other disorders, mainly due to the decrease in its antioxidant activity. In this article, the known negative effects of UA are reviewed, as well as the much less-known possible positive actions, and their therapeutic implications.
- Multi-Link Vision stent vs. first-generation drug-eluting... Background: Since its introduction, the cobalt chromium alloy MULTI-LINK VISION stent (MLV) has been extensively investigated thus leading to the largest amount of data so far available for a bare metal stent. Aim and Methods: Systematic review and meta-analysis (according to Cochrane collaboration guidelines) aiming at summarizing the real world safety and efficacy of MLV stent. Endpoints of interest were: major adverse events [(MAE) combination of overall death and non-fatal myocardial infarction, MI], and target vessel revascularization (TVR). Rate of stent thrombosis was also assessed. Results: Eleven studies finally retrieved totalling 5539 patients [7 study registries, 4243 patients and 4 randomized controlled trials (RCTs) comparing MLV vs. first generation of drug-eluting stent (DES) (paclitaxel or sirolimus eluting), (RCTs) 1296 patients]. Across study registries, at a mean follow-up of 11.1 months, MLV was associated with a 5.3% risk of MAE, 3% of death, 2.3% of MI and a 9% of TVR. Risk of ST was 0.5%. Compared to first generation of DES in RCTs, at a mean follow-up of 10.5 months, MLV achieved similar results in terms of MAE, death and MI. On the other hand, MLV was associated with a double risk of TVR [OR 2.01 (1.34–3.01), P < 0.001, number needed to treat 18 (13–40)]. Overall, in stent late loss with MLV was 0.81 mm (±0.51), while the in segment late loss was 0.61 mm (±0.5). Risk of stent thrombosis was equivalent. Of note, performance of MLV in terms of safety, efficacy and risk of repeat revascularization was quite consistent across all the published studies, despite inherent differences in study design, clinical setting, complexity of the lesions and ethnicity. Conclusion: Compared to first-generation DES, MLV showed substantial equivalence with respect to hard clinical endpoints. Data are consistent in study registries and RCTs meaning that the overall performance of MLV is quite predictable and reproducible into the wide spectrum of clinical settings.
- Gender variation of exercise-induced anti-arrhythmic prot... Background: Regular physical activity (PA) has shown substantial cardiac benefits. We sought to investigate whether habitual PA is associated with changes of the electrical action potential duration, as it is represented by the QT duration on a rest ECG, in a population based sample of middle-aged and elderly individuals of Ikaria island. Methods: In a cross-sectional survey 1071 inhabitants of Ikaria Island (65 ± 13 years, 47% males) were enrolled. PA was estimated by means of IPAQ classifying the participants into low, moderate and vigorous group. QT duration was measured from a surface electrocardiogram; while using Bazett's formula the heart-rate-corrected QT (QTc) was calculated. Results: Among participants, 85% reported at least moderate PA levels. Women in the ‘vigorous’ and ‘moderate’ PA level compared to those in the ‘low’ PA level had significantly shorter QTc (408 ± 2 ms vs. 411 ± 1 ms vs. 419 ± 2 ms, P = 0.001, respectively). In contrast, no significant difference in QTc according to PA levels was observed in men (P = 0.053). Linear regression analysis revealed that PA level was significantly associated with shorter QTc in women after adjustment for established confounders; while no such association was evident in men. Furthermore, compared to the ‘low’ PA group, women in the ‘vigorous’ PA group were 5.5-times less likely to have QTc interval above 450 ms (P = 0.031). Conclusion: Increased PA is associated with shorter QTc interval only in middle-aged and elderly women of Ikaria Island irrespectively of participant's habits or medical conditions, illustrating gender differences in the cardioprotective effect of habitual exercise.
- Chronic kidney disease prevalence and secular trends in a... Introduction: Most UK laboratories use the MDRD4 formula to estimate glomerular filtration rate (eGFR), but this may exaggerate chronic kidney disease (CKD) prevalence. In a large adult population, we examined the impact of the more accurate CKD-EPI formulae on prevalence estimates, and on secular trends in prevalence. Methods: We extracted all serum creatinine (SCr) results for adults, processed in our laboratory during two 1-year periods (2004, 2009–10). To minimize the effect of acute illness, a patient's lowest SCr was used for each period. eGFR (traceable to isotope dilution mass spectrometry value) was calculated using the MDRD4 and CKD-EPI formulae. Prevalence estimates were compared, with sub-group analysis by age and sex. Results: In 2004, 102 322 patients had SCr tested (35.4% of the adult population), rising to 123 121 (42.3%) in 2009–10. The proportion tested rose with age to 86% of 85- to 89-year olds. The prevalence of CKD stages 3–5 was lower with the CKD-EPI formulae than the MDRD4 formula. The CKD-EPI formulae reclassified 17 014 patients (5.8%) to milder stages of CKD, most commonly from eGFR 60–89 ml/min/1.73m2 and CKD stage 3A, in women, and in those <70 years old. 5172 patients (1.8%), mostly elderly women, were reclassified to more severe stages of CKD. Between the two time periods, the prevalence of CKD stages 3–5 rose from 5.44% to 5.63% of the population using MDRD4, but was static at 4.94% with CKD-EPI. Conclusion: The CKD-EPI formulae, which are more accurate than the MDRD4 formula at higher GFR, reduced the estimated prevalence of CKD stages 3–5 by 0.5% in 2004 and 0.7% in 2009–10. The greatest reclassification was seen in CKD 3A, particularly amongst middle-aged females. The minor rise in CKD prevalence between 2004 and 2009–10 seen with the MDRD4 formula was not confirmed with the CKD-EPI formulae. The CKD-EPI formulae may reduce overdiagnosis of CKD, but further assessment in the elderly is required before widespread implementation.
- An audit of acute bacterial meningitis in a large teachin... Background: Acute bacterial meningitis (ABM) is a rare disease associated with severe neurological sequelae and death. Clinical features on admission may be subtle and thus delay recognition. Previous studies have shown association between early administration of antibiotics and favourable outcomes. Aim: To examine the presenting clinical features of patients aged >15 years with ABM admitted to a University teaching hospital. To audit investigations and treatment including lumbar puncture (LP), computed tomography (CT) and antibiotics against British Infection Association guidelines. Design: Retrospective observational audit. Methods: Hospital records were reviewed for presenting clinical features and timing of CT scan, LP and antibiotics. Results: Records of 39 patients with ABM were reviewed. The classical triad of fever, neck stiffness and altered mental state was present on admission in only 21% of cases. LP was contraindicated in 69% of cases. Immediate LP was carried out in only 17% of those who had no contraindication. Antibiotics were administered after a median of 79 min (interquartile range 24–213 min); 65% were given within 3 h after arrival. Eighty-five percent of patients had antibiotics in accordance with local guidelines. Conclusions: In patients with ABM, the classical clinical features are uncommon on arrival to hospital and frequently evolve following admission. The majority of patients have contraindications to immediate LP. Efforts should be made to facilitate immediate LP performed in the Emergency Department when there are no contraindications. Earlier administration of antibiotics in cases of suspected ABM and close review following admission is recommended.
- Vitamin D and the social aspects of disease Background: The strong association between socio-economic disadvantage and poor health in northern Europe and North America causes great public health concern but as the mechanism is not understood, government actions have been completely unsuccessful. The social gap continues to widen. Aim: I propose that an important mechanism involved is relative deficiency of vitamin D in the socio-economically disadvantaged people. Design: The evidence is presented by explaining apparent paradoxes, together with the analogies of geography, season and ethnicity. Vitamin D studies are also demonstrated. Method: The picture is put together according to Hill's criteria of causation: strength of association, consistency of association, temporality, biological gradient, plausibility, coherence, experimentation and analogy. Results: Hill's criteria of causation are met, acknowledging that they are pragmatic and not absolute. The associations between vitamin D deficiency and socio-economic deprivation are supported by analogies of geography, seasonality and ethnicity. There is also biological plausibility. The paradoxes of Albania and India show that health disadvantage and socio-economic disadvantage are not necessarily connected, if relative deficiency of vitamin D is the mediating biological factor. Conclusion: The poor health and average early death of the socio-economically disadvantaged in the UK, together with the widening social gap of health, can be explained by relative deficiency of vitamin D. At present there is no explanation and attempts by government to close the social gap have failed. The understanding presented gives an important opportunity to improve the health disadvantages of the socio-economically disadvantaged.
- The experiences of cancer patients Objectives: To assess the needs of cancer patients for information about their condition and to understand the psychological impact of their illness. Background: The discussion of prognosis and treatment options in the palliative setting is an important and difficult part of oncology practice. To evaluate this, we examined the experiences of cancer patients of the physical and psychological impact of their disease on their life, and their opinions on the communication of end-of-life decisions and treatment options. Methods: A patient questionnaire was designed that encompassed communication regarding treatment and prognosis, quality-of-life attitudes subsequent to cancer diagnosis, end-of-life care and cancer drug funding. One hundred and twenty-five patients with a diagnosis of cancer were asked to participate and 96 questionnaires were completed and available for analysis. The questionnaire consisted of 63 questions and was completed in both an inpatient and outpatient setting. Results: This survey brought to light a number of controversial issues in cancer service provision, highlighting the emotional and psychological changes brought about by a cancer diagnosis. Major concerns of our patients include fear of death and pain, changes in interpersonal relationships and financial constraints. Only 66% of the patients wanted to be given a prognosis by their clinicians and just 70% of the patients recalled being given a detailed prognosis. 11% of the patients were not prepared to undergo palliative treatment. In all, 7% were not prepared to accept treatment for 1 year and 2% for 5 years of life in exchange for the potential side effects of cytotoxic chemotherapy. 12% of the patients would not want to be in possession of the information that they were in the terminal phase of the illness with a short time to live and 16% would not want this discussed with their next of kin. Conclusions: This study informs medical professionals about the importance of tailoring information to the needs of the individual patient, and we feel it provides insights into the successes and failures of our communication with cancer patients. It is important that difficult discussions are personalized to the individual patients’ wishes. These can vary dramatically both in the area of disclosure of bad news in prognosis and in end-of-life decision making. This study provides compelling evidence for good advanced care planning at an early stage in the management of patients with terminal cancers.
- Concomitant ST-elevation myocardial infarction and deep v...
- Obstructive sleep apnoea as a cause of headache presentin...
The American Journal of Medicine
- Can Primary Care Medicine Be Saved? The number of medical students who choose to train for a career in primary care internal medicine has been falling for decades and has now reached a critical point. If the trend is not reversed, many patients in the US will be left without access to a primary care internist. I often get desperate phone calls from my cardiology patients asking me to help them find a primary care internist who is still accepting new patients. A similar situation exists in primary care family medicine. Is the field of primary care medicine about to become extinct? And why don't more young physicians choose this satisfying career path?
- The D-batable Parathyroid Hormone Plateau SEE RELATED ARTICLE p. 1165
- Calcium Supplements and Risk of Myocardial Infarction: A ... Calcium supplements are prescribed widely to promote bone health, including the treatment and prevention of osteoporosis, a major cause of morbidity and mortality in older people. A recently reported meta-analysis of randomized trials of calcium supplements showed no significant increases in total cardiovascular disease or stroke but a significant 27% increase in myocardial infarction. The authors, as well as the accompanying editorialist, stated that any level of risk is unwarranted and judged that the widespread use of calcium supplements is causing high morbidity and mortality. In this commentary, we commend the authors for their formulation of an important and timely hypothesis but provide a cogent rationale that this hypothesis has not been tested adequately and that any judgment of causality is premature and unwarranted.
- Management of the Metabolic/Bariatric Surgery Patient Abstract: There is currently a global pandemic of obesity and obesity-engendered comorbidities; in particular, certain major chronic metabolic diseases (eg, type 2 diabetes) which markedly reduce life expectancy and quality of life. This review is predicated on the fact that management of the obese patient is a primary concern of all physicians and health care providers, and that metabolic/bariatric surgery is a highly successful therapeutic option for this disease.
- Care of the Adult Hodgkin Lymphoma Survivor Abstract: Of those individuals diagnosed with Hodgkin lymphoma, 85% will survive and may be affected by residual effects of their cancer and its therapy (chemotherapy, radiation therapy, stem cell transplantation). Hodgkin lymphoma survivors are at risk of developing secondary malignancies, cardiovascular disease, pulmonary disease, thyroid disease, infertility, premature menopause, chronic fatigue, and psychosocial issues. These conditions usually have a long latency and therefore present years or decades after Hodgkin lymphoma treatment, when the patient's care is being managed by a primary care provider. This review summarizes these unique potential medical and psychologic sequelae of Hodgkin lymphoma, and provides screening and management recommendations.
- Cellulitis: Definition, Etiology, and Clinical Features Abstract: Cellulitis is a common condition seen by physicians. Over the past decade, skin and soft tissue infections from community-associated methicillin-resistant Staphylococcus aureus have become increasingly common. In this article, the definition, etiology, and clinical features of cellulitis are reviewed, and the importance of differentiating cellulitis from necrotizing soft tissue infections is emphasized. Empiric antimicrobial recommendations are suggested, including the most recent recommendations from the Infectious Disease Society of America.
- Sleep Disordered Breathing in the Elderly Abstract: Sleep-disordered breathing, especially obstructive sleep apnea (OSA), has a high prevalence among the elderly, where it may present with atypical symptoms. Untreated OSA can reduce quality of life and have adverse health consequences. Effective treatment is available, so all physicians treating the elderly should be aware of the clinical presentation, diagnostic methods, and treatment options for OSA.
- Contrast-induced Nephropathy Risk Assessment in Real Worl... A 56-year-old woman with a history of coronary artery disease with previous 3-vessel coronary artery bypass grafting, ischemic cardiomyopathy, and diabetes mellitus presented with several months of exertional chest discomfort. She was referred for cardiac catheterization after reversible inferior ischemia was demonstrated on a stress myocardial perfusion scan. The catheterization showed an occluded saphenous vein graft to the right coronary artery and focal right coronary artery stenosis. Overlapping drug-eluting stents were placed in the right coronary artery utilizing a total of 200 cc of iodixanol during both the diagnostic and interventional procedure. At baseline, her serum creatinine was 1.2 mg/dL for an estimated glomerular filtration rate of 46 mL/min/1.73 m2, and her hemoglobin was 13 gm/dL. On postprocedure day 2, her serum creatinine rose to 1.9 mg/dL, peaking at 3.2 mg/dL on postprocedure day 4. She was nonoliguric throughout her hospital course. She was discharged from the hospital on postprocedure day 5, with her serum creatinine returning to baseline 2 weeks after discharge.
- Steroid-responsive but not Rheumatologic An odd cluster of signs and symptoms responded to steroids, but the cause was elusive. A 75-year-old female with a history of hypertension and cerebrovascular accident presented with intermittent lethargy, fevers to 104° F (40° C), dyspnea, and a 1-week history of severe pancytopenia. Her symptoms began 4 months earlier with generalized lethargy and increasing dyspnea, prompting admission at a local hospital. Bilateral pleural effusions and a small pericardial effusion were found, and a thoracentesis identified the effusions as exudative. Cultures and cytology were negative. The patient was discharged on a steroid taper for presumed exacerbation of chronic obstructive pulmonary disease.
- A Blast from the Past Common complaints tend to be explained by common conditions, but sometimes that assumption is wrong. A 56-year-old man presented with cough, skin lesions, and left knee pain. Five months earlier, he had developed a cough that occasionally produced blood-tinged sputum. A smoker, he was told he had bronchitis, for which he received courses of levofloxacin, inhaled bronchodilators, and inhaled corticosteroids; this was followed by a course of amoxicillin. There was no noticeable improvement, and 5 weeks prior to presentation at The University of Illinois at Chicago, his left knee became painful and swollen. At the same time, he developed skin lesions that a dermatologist diagnosed as acne; he was treated with doxycycline for 3 weeks. When his skin worsened to the point that he thought it embarrassing, he presented for a second opinion.
European Journal of Internal Medicine
- Editorial Board
- Contents
- Heart failure and non-ST-segment elevation myocardial inf... Abstract: Up to 15% of patients with NSTEMI present at admission with heart failure. Scientific evidence for its management is limited but much progress has been made during the last years. Our purpose was to review the last data concerning heart failure in NSTEMI and perform an update on the subject, with the following findings as main highlights. As Killip classes III and IV, Killip class II onset in the context of NSTEMI has also proven bad prognosis significance. Beta-blocker therapy has proven benefit to patients with Killip class II in observational studies and small trials. Angiotensin-converting enzyme inhibitor therapy shows stronger evidence of benefit in patients with heart failure than in patients without it. Eplerenone is indicated for patients with left ventricular dysfunction and heart failure or diabetes mellitus. Implantable cardioverter defibrillators improve survival in patients with severe ventricular dysfunction after a myocardial infarction. Cardiac resynchronization therapy indications must be carefully assessed due to the high rate of implants that do not fulfill guidelines indications. In conclusion, heart failure during a NSTEMI is a common and meaningful situation which warrants careful management and further investigation to reach stronger evidence for clinical recommendations.
- Antisense therapy in the treatment of hypercholesterolemia Abstract: Cardiovascular disease, the leading causes of death worldwide, is a “preventable” pathology, so that accessible and affordable interventions should be established to target the leading risk factors, including hypercholesterolemia. Although statin based therapy is commonplace in primary and secondary prevention, several economical, clinical and safety issues have been raised, so that there is ongoing research into new, safer and more effective agents to be used alone or in combination with existing cardiovascular drugs. Antisense oligonucleotides (ASOs) are a class of short, single-stranded synthetic analogs of nucleic acids that bind to a target mRNA, preventing its translation and thereby inhibiting protein synthesis. Apolipoprotein B-100 (apoB-100) is the major protein moiety of the atherogenic lipoproteins LDL and Lp(a), thus representing the ideal target for antisense therapy. Two anti-apoB100 (i.e., ISIS 301012 and ISIS 147764) and one anti-apolipoprotein(a) (i.e., ASO 144367) have already been developed and tested in some animal and human trials, providing promising results in terms of significant reduction of both LDL and Lp(a). Nevertheless, some safety issues – especially injection-site reactions and potential hepatotoxicity – have also emerged, thereby slowing down the large clinical diffusion of these agents. The present article provides an update on clinical data regarding antisense therapy targeting human apolipoproteins, highlighting the benefits and the potential risks of this innovative therapeutic approach for hypercholesterolemia and hyperlipoproteinemia(a).
- An overview on cognitive aspects implicated in medical de... Abstract: Cognitive theories on decision making show that individuals often do not decide in a full and rationale way, but instead use cognitive strategies that allow them to overcome the limitations imposed by their limited rationality and the difficulties derived from uncertainty. The first part of the paper will discuss the role of heuristics and biases in medical decision making. This is an interesting field of research since medical decisions must be fast and are often complicated by rapid changes in the patient's clinical condition, uncertain prognosis and unexpected or uncontrollable treatment effects. In such contexts individuals are forced to rely on heuristics to assist them in taking decisions which can sometimes produce cognitive biases.The second part of the paper will be dedicated to discussing ways in which the patients' decisions can be improved. The role of the shared decision making approach will be discussed as well as the role of decision aids. Based on personal information coming from the physical and psychological characteristics and needs of the patient, decision aids give information about specific options and outcomes related to the patient's disease. Provided with a set of well-defined alternatives, patients are assisted in taking their preferred decisions, especially when there is more than one medically reasonable opinion available. Moreover, decision aids facilitate and support the shared decision-making, a process by which patients and physicians discuss and evaluate the alternatives for a particular medical decision together.
- Extra-articular manifestations of ankylosing spondylitis:... Abstract: Ankylosing spondylitis (AS) is the most frequent and most severe subtype of spondyloarthritis and can be an outcome of any of the other spondyloarthritis subtypes. It primarily affects the axial joints, most notably the sacroiliac joints. Other sites of involvement include the spine, peripheral joints, and entheses (capsules, ligaments, and tendons). Inflammatory enthesopathy progressing to ossification and ankylosis is the pathologic basis for the disease. Extra-articular manifestations vary widely in terms of both frequency and severity. The most common extra-articular manifestations are represented by uveitis, bowel disease, heart, lung, skin, bone and kidney involvement. This review focuses on prevalence and clinical characteristics of the most common extra-articular manifestations in AS, and discuss the diagnosis and therapeutic difficulties that rheumatologists faces when dealing with such manifestations. The advantages of treatment with non-steroidal anti-inflammatory drugs (NSAIDs), especially if continuous use is envisaged, should be weighted against possible gastrointestinal and cardiovascular disadvantages. In the presence of history of gastrointestinal complaints or a high cardiovascular risk, NSAIDs should be used with caution. TNF inhibition has demonstrated effectiveness in the treatment of AS symptoms and all currently available anti-TNF agents appear to have similar efficacy. However, the efficacy of anti-TNF agents varies in the presence of extra-articular manifestations. Etanercept appears to have very little effect on inflammatory bowel disease and limited efficacy on the course of uveitis probably inferior to the monoclonal antibodies infliximab and adalimumab.
- Clinical approach to severe Clostridium difficile infecti... Abstract: The rising incidence of Clostridium difficile (C. difficile) infection or CDI is now a problem of pandemic proportions. The NAP1 hypervirulent strain of C. difficile is responsible for a majority of recent epidemics and the widespread use of fluoroquinolone antibiotics may have facilitated the selective proliferation of this strain. The NAP1 strain also is more likely to cause severe and fulminant colitis characterized by marked leukocytosis, renal failure, hemodynamic instability, and toxic megacolon. No single test suffices to diagnose severe CDI, instead; the clinician must rely on a combination of clinical acumen, laboratory testing, and radiologic and endoscopic modalities. Although oral vancomycin and metronidazole are considered standard therapies in the medical management of CDI, recently it has been demonstrated that vancomycin is the more effective antibiotic in cases of severe disease. Moreover, early surgical consultation is necessary in patients who do not respond to medical therapy or who demonstrate rising white blood cell counts or hemodynamic instability indicative of fulminant colitis. Subtotal colectomy with end ileostomy is the procedure of choice for fulminant colitis. When applied to select patients in a judicious and timely fashion, surgery can be a life-saving intervention. In addition to these therapeutic approaches, several investigational treatments including novel antibiotics, fecal bacteriotherapy and immunotherapy have shown promise in the care of patients with severe CDI.
- Combining patient administration and laboratory computer ... Abstract: Several approaches to measuring the quality of hospital care have been suggested. We propose the simple and objective approach of using the health related data of the patient administration systems and the laboratory results that have been collected and stored electronically in hospitals for years. Imaginative manipulation of this data can give new insights into the quality of patient care.
- Should we routinely treat patients with autoimmune/rheuma... Abstract: It is well established that hepatitis B virus (HBV) reactivation is common among patients with various hematological or neoplastic diseases who receive chemotherapeutic agents without appropriate antiviral prophylaxis and is associated with significant morbidity and mortality. A number of recent studies have indicated that treatment with anti-tumor necrosis factor (TNF) agents in patients with autoimmune/rheumatic diseases carries a similar risk. Furthermore, appropriate pre-emptive treatment with oral antivirals appears to significantly reduce that risk and should be routinely implemented in clinical practice. Similar data are available for B-cell depleting agents like rituximab from the hematology literature, indicating the need for a similar approach in patients with autoimmune diseases receiving such agents.
- Should we routinely treat patients with autoimmune/rheuma... Abstract: Hepatitis B virus (HBV) infection affects a large part of the world population. Different virological HBV categories have been identified and managing strategies for immunosuppressed patients with serological signs of current or past HBV infection has been proposed. Those strategies developed to manage patients in the haematology setting are based on strong evidence. Instead, management of such patients in the rheumatologic setting, especially those treated with biologic response modifiers, is mainly based on data derived by case reports and expert opinions. More data are needed to better manage these patients in case of signs of current or past HBV infection.
Canadian Medical Association Journal current issue
- National benchmarks for treatment of seniors' mental heal...
- First aid for psychoses [News]
- BC First Nations to run own health system [News]
- European nations launch tax attack on unhealthy foods [News]
- Accountability lacking under health accord [News]
- Tobacco control measures under industry assault [News]
- "Poor tax" urged to address mental health issues [News]
- Early hormone replacement therapy may yield benefits, res...
- Nothing to sneeze at [News]
- Briefly [News]
ACP Internist: Current Contents
- Sports internists treat players as patients These internists turned their own athletic pursuits into careers for professional sports teams, treating high-caliber athletes as they practice and play. When working the sidelines, it's just another day not at the office.
- Managing the elderly with cardiovascular disease As patients are living longer, they're seeking more care for their cardiovascular diseases, as well as the accompanying comorbidities such as diabetes. Effective therapy is possible in the older population, say the experts.
- Medical missions in Iraq help train next generation of do... U.S. military physicians are helping to train Iraq's next generation of doctors, as well as helping to restore an infrastructure smashed by decades of neglect, then combat.
- Government expert encourages transition to electronic rec... Internist Farzad Mostashari, MD, takes over as the nation's "EHR czar," through the office of the national coordinator for health information technology. He answers questions on the progress of this transition.
- Treating HIV, teaching trainees motivate this internist Harvard Medical School's first African-American full professor, and Mass General's first African-American female professor, finds that mentoring and teaching are her greatest accomplishments.
- New drugs approved for acute coronary syndromes, HIV Recalls, warnings, approvals and other regulatory news.
- Thinking about our thinking as physicians Cognitive errors have been the bane of making the right diagnosis. The final installment of the Mindful Medicine column reviews the past three years' discussions of traps and pitfalls that physicians must account for when presented with patients who aren't getting any better, often despite multiple encounters in the health care system.
- Electronic medical records have yet to fulfill their pote... An admittedly technophobic internist recounts her first day using an electronic health record. Her lesson learned: Internists must take control of their design and use to make the most of these new systems.
- Mandated health care cuts don't equal health care reform Automatic cuts mandated by the Budget Control Act of 2010 make it more likely that Congress will deadlock on thoughtful spending adjustments in favor of cuts to primary care education and training, or simply make across-the-board cuts to physician reimbursement, instead of looking at genuine ways to reduce health care spending.
- Malpractice suits are more than just a claim Readers respond to ACP Internist's coverage.
ACP Internist
- Casting light on the actual costs of medical care I really like this idea, but ... well, see after the quote from "Exposing the Cost of Health Care" at Technology Review: "It's easy to compare prices on cameras, vacations, and homes. But in the United States, patients fly blind when paying for health care. People typically don't find out how much any given medical procedure costs until well after they receive treatment, be it a blood draw or major surgery."This lack of transparency has contributed to huge disparities in the cost of procedures. According to Castlight Health, a startup based in San Francisco, a colonoscopy costs anywhere from $563 to $3,967 within a single zip code. EKGs can range from $27 to $143, while the price for a set of three spinal X-rays varies from as little as $38 to as high as $162."When someone else is picking up the tab, mystery pricing is not much of a problem. But these days, even the 59.5 million Americans who get health benefits through large self-insured employers are increasingly expected to pay a percentage of the costs for their medical care."Castlight aims to do as its name suggests: cast light on the actual costs of medical care, so that people can make informed decisions ..."Finally! Some price transparency! Huzzah! I want people to recognize that spending money when there's no clue to the charge (not cost, charge) is directly responsible for a ton of the runaway cost in medicine.This is better than nothing. It is, and while I don't begrudge people making money on their great idea, is this the best model?"The company sells its tool to self-insured employers, who pay a fee per covered member per month, and in turn offer employees access so they can become more responsible users of their benefits. It has raised $81 million in venture funding to date. Current customers include Safeway and Life Technologies, a leading maker of genomics tools.""'Castlight is further along than anybody else in helping big employers show their employees that the individual decisions they make on health care actually do have a cost that affects benefits and wages,' says Matthew Holt, co-chairman of Health 2.0, a health-care consultancy firm."Okay, better than nothing, and a start in the right direction. Good for them.This post by Allen Roberts, MD, MS, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.
- Who should manage cancer survivors after their treatment ... It is completely understandable if you associate the term "cancer survivor" with an image of glamorous, defiant Gloria Gaynor claiming that she will survive. Or maybe with a courageous Lance Armstrong in his quest to reclaim the Tour de France. Or perhaps it is linked for you with heroic rhetoric and pink-related racing, walking and shopping.I never call myself a survivor because when I hear this term, I recall my experience following each of four cancer-related diagnoses. It has not been triumphant. It's been terrifying and grueling. It hasn't taken courage to get through the treatment. It's taken doing the best I can. I am not still here because I am defiant. I am here because I am lucky, because I am cared for by good clinicians who treated my cancers based on the best available evidence, and because on the whole, I participated actively in my care. But mostly I am here because each successive diagnosis was made as a result of being followed closely with regular checks and screenings and because my doctors responded effectively to questionable findings and odd symptoms.There are 12 million Americans living today who have been treated for cancer. Not only are we at risk for recurrences but, as Dr. Julia Rowland, director of the Office of Cancer Survivorship at the National Cancer Institute, notes, "Research shows that there are no benign therapies. All treatment is potentially toxic and some therapy may itself be carcinogenic. Today, people are living long enough to manifest the health consequences of efforts to cure or control their cancer."Who amongst our clinicians is responsible for helping us watch out for those consequences for the balance of our lives?Good question.Recent survey research published in the Journal of General Internal Medicine asked primary care clinicians and oncologists who should monitor and care for cancer patients once they finish active treatment. Almost two-thirds of oncologists had little confidence in the skills of primary care clinicians to order appropriate tests and care for the late effects of breast cancer treatment. And many primary care clinicians agreed, only 40% of primary care clinicians expressed confidence in their own knowledge about testing for recurrence and late effects.But the demand for oncologists to treat active cancer is already high, and the number of people who have been treated for cancer is growing. Many oncologists are unwilling or unable to assume full responsibility for active, ongoing monitoring of all their patients in perpetuity. However, their lack of confidence in their generalist colleagues' ability to provide survivorship care makes smooth handoffs after treatment problematic. In addition, in the survey cited above, although oncologists said that they provided treatment summaries or care plans to primary care clinicians a majority of the time, primary care clinicians reported receiving them a minority of the time. Further, while oncologists reported communicating frequently with other physicians to clarify their respective roles in follow-up care for cancer survivors, primary care clinicians' perceptions were that this communication occurred infrequently.And so who is it, again, who will take responsibility for our survivorship care? And how is such care to be coordinated?It's true that caring for us requires specialized knowledge. Since 1996, the Office of Cancer Survivorship at the National Cancer Institute has funded research on the phenomenology of cancer treatment: the outcomes and prevalence of persistent fatigue, pain syndromes, sexual dysfunction, memory problems and late effects such as cardiac problems, second malignancies, stroke, and obesity that are associated with cancer and its treatment.Findings from these studies are a driving force for the need for treatment summaries and care plans that address our ongoing challenges. The Office of Cancer Survivorship has worked in collaboration with many others to push every possible lever, from supporting Institute of Medicine and President's Cancer Panel reports focusing on this issue, to encouraging adoption of survivorship care planning as part of the quality care standards developed by the American Society of Clinical Oncology, the National Coalition of Cancer Survivorship, the American Cancer Society and the American College of Surgeon's Commission on Cancer, to ensure that treatment summaries and follow-up care recommendations are used as the basis of a "survivorship plan" for each patient. Efforts to address our need for survivorship monitoring and care are not limited to the cancer sector: Michael Barr, MD, FACP, of the American College of Physicians reports that there is keen awareness of the need to bridge the generalist/specialist divide, especially as patient-centered medical homes are becoming the delivery model of choice to coordinate care for people with chronic illnesses. He described the guidance ACP has developed to provide patient-centered care that ensures that information is shared and flows across the health system to support people as they move through various transitions in their care. "It is incumbent on the profession to be sure that evidence-based guidelines, clinical decision support, collegial consultations via phone/email, and life-long learning are in place to help make sure that appropriate knowledge resides at the rights points of care - and that clinicians have the capability to recognize what they don't know but need to know, and how/where to find that information," Dr. Barr said. So the stage is set, the ground is laid, it should be possible for oncologists to triage patients when they finish active treatment to hand over the care of the less complicated among us to primary care clinicians, to share the care of some of us with them and to maintain full responsibility for survivorship care for those of us with multiple cancers and complicated co-morbidities.What's standing in the way of this solution?I asked Paul Wallace, an oncologist formerly with Kaiser Permanente (now with the Lewin Group) to speculate about some of the barriers. He talked about how: "…Cultural factors play a role ... the growing reliance over decades for patients to rely on specialists to solve the tough problems ... for oncologists, cancer survivorship is a victory and they need to regularly see success in order to maintain their motivation and balance." And: " ... The practical barriers are considerable: the compartmentalization of practices, especially medical records, are exacerbated by the complexity and language of cancer treatment ... the time required to summarize a patient's treatment and its implications in a form that would be useful for a generalist with no reimbursement for doing so." And: "...There are undeniable incentives for oncologists to retain patients in fee-for-service settings, especially with the threat of cuts to reimbursement on top of escalating expenses."These are very real barriers. And there are individuals and organizations, oncologists, generalists and patient advocates, who are deeply committed to overcoming them. Nevertheless, I am concerned that cancer survivorship planning and care will be eclipsed by the flux in health care delivery, the ambivalence of oncologists and primary care providers about taking on (and taking seriously) caring for cancer survivors, and the growing economic pressures on patients and our families.Those of us who have been treated for cancer need to hear from our physicians, primary care and oncologists alike, that survivorship care is as important to us now as treatment was before, and that they will help us to strategize about how to live long and well with the risks and effects of our disease. And then we need them to stick with us and with those strategies, modifying them as our health changes and new findings emerge. We cannot, and most of us will not, do this without the leadership of our clinicians.And without that leadership, being a "cancer survivor" will remain as apparitional and as insubstantial as the images of happy pink-garbed walkers, a sleek biker and the hopeful words of a glamorous R&B singer.Jessie Gruman, PhD, is the founder and president of the Washington, D.C.- based Center for Advancing Health. She is the author of Aftershock: What to Do When You or Someone you Love is Diagnosed with a Devastating Diagnosis. This post originally appeared at the Prepared Patient Forum.
- Magic Johnson lives for two decades with HIV A recent article in the Washington Post has a video clip from CNN, 20 years ago, when basketball star Magic Johnson announced on TV that he had HIV, the virus that causes AIDS. The date was Nov 7, 1991."Where were you when Magic made his announcement? What were your thoughts on Johnson and HIV/AIDS that day and how have they changed?" asks Matt Brooks in his column.I can't quite recall where I was. Probably I was at the hospital working, possibly even taking care of a patient with HIV. But I do remember thinking how much courage it must have taken for him to come out with it.He understood, likely, that he would die soon, and his doctors probably thought the same. There were only two antiviral drugs approved for HIV back then. There was so much stigma, and fear.Today you can see and listen to him in an interview on ESPN.It's great to see Magic Johnson back in the news, even if it's (just) in a sports sections, and to be reminded that he's alive, doing OK. The condition we thought was a death sentence has become a chronic illness, with so many drugs available for treatment it's hard to keep track.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.
- QD: News Every Day--It's true: Smaller plates encourage s... A simple optical illusion might encourage better eating habits, researchers found.The Delboeuf illusion makes equal size circles appear to be different sizes by surrounding them with larger or smaller concentric rings. Applied to eating, smaller plates make the food servings appear larger. One problem is that the size of commercially available dinnerware has increased from 9.6 inches to 11.8 inches in the past century. Eating only 50 calories a day more as a result equals enough calories to add five pounds of weight annually.Practical implications of the research include encouraging people to replace larger plates and bowls with smaller ones, choose plates that contrast starkly with food, and even choose tablecloths that match their dinnerware, the researchers noted. Those with eating disorders or elderly people who need to eat more could follow the opposite advice to improve their intake. Researchers conducted five studies on different variables to test how the Delboeuf illusion affected how people dish out their dinner. Results, which were published online Nov. 11 in the Journal of Consumer Research, are also published in full at the researcher's university website.The first study isolated plate size. College students were shown a 9 cm bowl filled with tomato soup. They then tried to match the serving at another table that had one of seven differently sized bowls with diameters larger and smaller than 9 cm.Participants poured 8.2% less soup into the three smaller bowls and 9.9% more into the three larger bowls. Those who poured into a similarly sized control bowl served an insignificant .9% less.Next, the students looked at a target serving of soup in a randomly sized serving bowl. The bowls were shaped so that no matter the diameters of the bowl, the soup itself had a consistent diameter in the bowl. The students were asked to determine how much larger or smaller the soup was in the bowl compared to the target diameters. Participants perceived the diameter of the smaller bowls to be 8.9% larger than the diameter of the target serving and perceived the diameter of the larger bowls as 8.6% smaller. The similarly sized control bowl was seen as an insignificant .8% larger.The second of the five studies looked at color contrast between dinnerware and a tablecloth. Students were asked to look at a target serving of cereal and then serve themselves a similar diameter at four stations (large and small white bowls sitting on black and white tablecloths).Students in the high-contrast condition served 9.8% more using large plates and 13.5% less on the smaller plate. The low-contrast station significantly reduced overserving on large plates (9.8% vs. .3%) and reduced undeserving on small plates (-13.5% vs. -4.7%).The third of the five studies assessed attentive servers to inattentive ones. Large and small plates were shown with a target size of cereal, but half the subjects were shown the servings for less than two seconds while the others were allowed one minute to study the portions. Students then had to draw a circle around the serving with the same diameter as the target serving size on the smaller and larger plates. Inattentive students drew circles 8.3% larger on the larger plates and 11.2% smaller on the smaller plates. Attentive students drew circles 1% larger on larger plates and 7.2% smaller on larger plates, showing that mindful servers could adjust somewhat for the Delboeuf illusion.The fourth study directly told randomized participants about the Delboeuf illusion and its impact on serving sizes. Control and experimental subjects were then offered small and large plates. Plate size influenced serving sizes, but less so among informed subjects. Large plate servings were reduced from 10.6% more to 4.4% more and small plate servings were reduced from 7.1% to 4.3% less.The fifth study recruited adult lunch goers randomized to two buffet tables serving pasta in either red or white sauces, one sauce per each table. Once in line, the adults were randomly offered red or white plates that were 27.3 cm. The adults served themselves and a hidden scale recorded the serving amounts. A recommended serving of pasta according to the Food Guide Pyramid and the Diabetic Exchange System is 114.3 g.Those in low-contrast servings overserved significantly more pasta than high-contrast scenarios than low-contrast ones (182.7 g vs. 140.6 g). Low-contrast servings (red sauce on red plate, or white sauce on white plate) didn't differ much (184 g vs. 181.5 g), and neither did the high-contrast scenarios (141.5 g vs. 139.8 g). "The solution to our tendency to overeat from larger plates and bowls is not simply education. In the midst of hardwired perceptual biases, a more straightforward action would be to simply eliminate larger dinnerware--replace our larger bowls and plates with smaller ones," the researchers concluded. "It may be easier to change our personal environments than to change our minds."
- Do you need to ask your doctor 10 questions? The blog Shots posted a question primer to prepare patients for medical office visits with their doctors. A reaction to this appeared on Glass Hospital, where John Schumann, MD, FACP, offered his own wry version of the question list. My less wry, and drier response appears below. While I agree with Shots that education is power, a closer look at the question list demonstrates that the intent to educate may obfuscate instead. First, the post is entitled, "Ten Questions to Ask Your Doctor," suggesting that patients arrive at their physician's office armed with 10 inquiries spanning a spectrum of medical knowledge and philosophy including medical treatment strategy, physician qualifications, risks of treatment, medical treatment alternatives, choice of hospitals and even how to spell the names of their medications. (I guess Shots believes that spelling counts!)Some of the questions sound reasonable, but could patients make sense out of the answers? For example, Shots suggests asking, "Which hospital is best for my needs?" Patients often are focused on the choice of hospital, when they should be more interested in which physicians will be caring for them. While the hospital matters, it's much more important who will be performing your surgery, then where it will take place. Are patients equipped to evaluate hospital quality anyway? Is a good reputation or a shiny exterior a true surrogate for medical quality? Patients often have a negative view of a hospital based on an isolated anecdote, which they may not have even experienced first-hand. Another suggested question is, "How many times have you done this procedure?" Will this provide useful information for patients? I agree that for many medical procedures, a higher case volume means a lower risk of complications. But, will it enlighten a patient to know that the gastroenterologist has performed 2,000 colonoscopies or 5,000 or 10,000? Better questions, which can't be quantitatively answered, would be, "How many times have you done this procedure well, or, how many of your procedures were truly medically necessary?" I object to Shots' version of the "how many" question which simplistically reduces medically quality measurement to a check-off form, paying homage to the deities who gave life to the pay-for-performance beast. What really counts can't be counted. Paradoxically, what can be counted, will count.In addition, if you bring your doctor the 10-question list, be prepared for some frustration when your office visit ends and you've only covered the first three items on the list. There may not be time left for you to discuss the issue that brought you to see your doctor in the first place. It may take a few visits and a fair amount of dialogue for you to understand your physician's philosophy and style of medical practice. This important information can't be acquired by taking a multiple choice test or answering a series of questions. The question list on the blog Shots is a guide that needs to be prioritized. You simply can't cover them all in a single visit, and you shouldn't have to. Experienced physicians know that patients often want to cover every last medical concern and we will often begin a visit with a question from our own top ten list--"What are the one or two issues that we need to cover today?"Any questions? This post by Michael Kirsch, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
- Annual chest X-rays not useful for lung cancer screening It's been a disappointing month for proponents of screening.You remember what screening is? Screening is testing someone for a disease who does not have any signs or symptoms of that disease. In general it means testing a wide population for a specific disease. So if I have a chronic bloody cough and unintentional weight loss, my doctor isn't screening me for lung cancer. He's doing tests to diagnose or rule out lung cancer because I have suggestive symptoms for that disease. Got it?Lung cancer has long been the number one cancer killer in the U.S. So a screening test that would help save lives from lung cancer is much in demand. In the 1970s studies tested screening for lung cancer with annual chest X-rays. The trials did not find any benefit.Apparently those 1970s studies had some procedural flaws that made them unconvincing. And X-ray technology has improved in the last 30 years. So it was conceivable that chest X-rays got a bum rap and were actually a valuable screening tool. This prompted the National Cancer Institute to retest chest X-ray screening as part of its Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO), which is a large clinical trial testing various cancer screening tests.The results of the lung cancer portion of this trial were published in the Journal of the American Medical Association. Over 154,000 people were randomized to either receiving annual chest X-rays or to usual care by their physicians. There was no difference between the two groups in deaths from lung cancer.So that settles a question I thought was already settled. Healthy people don't benefit from periodic screening chest X-rays.This finding comes on the heels of other negative news about screening. The ovarian cancer branch of PLCO has also demonstrated that the blood test CA125 is not valuable for ovarian cancer screening. And just two weeks ago the U.S. Preventive Healthcare Task Force's recommended against PSA screening for prostate cancer.For lung cancer, there is some hope, however. A study in July showed that in a selected population of high-risk smokers screening with spiral CT scans saved lives.Avoiding unproven tests isn't just a matter of avoiding expense. Unproven tests (or tests proven not to help) cause more harm than good by leading to other invasive unnecessary tests. The informed patient doesn't want to be screened for everything. He wants only what has been proven to help.Learn more:Looking For Lung Cancer with A Yearly X-Ray Doesn't Reduce Deaths (Shots, NPR's Health Blog)X-Rays No Help against Lung Cancer (Wall Street Journal)Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (National Cancer Institute clinical trial page)Screening by Chest Radiograph and Lung Cancer Mortality (Journal of the American Medical Association)Spiral CT Scans Save Lives from Lung Cancer (my post about lung cancer screening with CTs)Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.
- QD: News Every Day--Elderly want longevity over quality, ... Don't assume elderly heart failure patients are assumed to prefer improved quality of life over longevity, study authors noted. The majority of them prefer longevity over quality of life, half expressed a desire for resuscitation if needed, and it was difficult to predict individual preferences.Researchers looked at patients' willingness to trade survival time for quality-of-life and the preferences for among 622 heart failure patients aged 60 or older participating in the Trial of Intensified vs. Standard Medical Therapy in Elderly Patients with Congestive Heart Failure. End-of-life preferences were assessed by using a time trade-off tool and one question concerning CPR preference. To assess time trade-off, patients were asked whether they preferred living 2 years in their current state of health or living 1 year in excellent health. If 1 year in excellent health was chosen, the patients were asked whether they would prefer 2 years in their current state of health or 6 months in perfect health. If 2 years in the current state were chosen, then they were asked whether they would prefer 2 years in their current state of health or 18 months in perfect health. The series continued until the choices were the same. This time point subtracted from 24 months derived the number of months of survival time that the patient would be willing to trade. End-of-life preferences were assessed at baseline, and at 12 and 18 months. In addition, CPR order during last hospitalization was assessed in patients who were included presently after discharge. Patients were divided into four groups: not willing to trade any survival time, willing to trade less than 6 months, 6 to 12 months, and 12 months. Results appeared in the European Heart Journal.In multivariable analysis, willingness to trade survival time increased with age, female sex, a reduced Duke Activity Status Index, Geriatric Depression Score, and history of gout, exercise intolerance, constipation and edema. But, the authors noted, even combining these variables did not result in reliable prediction. Of 603 (97%) patients who had a resuscitation preference, 51% wanted resuscitation, 39% did not, and 10% were undecided, with little change over time. Resuscitation orders were known in 430 patients, but they differed from patients' preferences 32% of the time. At baseline, 74% of the patients were not willing to trade any survival time for excellent health. Of the remaining patients, approximately equal groups were willing to trade up to 6 months, 6 months to 1 year, or more than 1 year. Patients aged 75 years and older were slightly more likely to be willing to trade any survival time, the proportion of those not willing to trade would still be 72% (at month 18, 75%). Patients indicating any willingness to trade survival time for symptom-free living differed in many ways from those unwilling to trade, the authors wrote. They were older, more often female, lived more often on their own and/or were not married, had more signs and symptoms of congestive heart failure and poorer quality of life. The authors wrote, "Openness and communication about prognosis, trajectories, and realistic treatment possibilities engender hope and allow patients to plan for their future. This applies to various decisions that confront (congestive heart failure) CHF patients, but may be particularly important with respect to (implantable cardioverter-defibrillator) ICD implantation, turning off the device, and treatment with purely symptomatic medical therapy that may even reduce survival."An editorial commented that patients must receive accurate information about life expectancy in order to make better choice about their end-of-life. This requires open and repeated conversations in a patient-centered environment."In patients whose prognosis is grim, the real question we should be asking is 'Given limited quantity of life, how can we maximize quality?'" the editorial stated. "As the end of life nears, the goals of care should also change, and the alleviation of adverse symptoms becomes the most important objective."
- HIPAA inhibits medical education through case studies It was an interesting tweet that referenced a soon-to-be-published case report from the Annals of Emergency Medicine (via @EmergencyDocs) that piqued my interest: "Thrilling case study: emergency doc cracked chest to save 42 y/o woman in cardiac tamponade after ablation therapy. http://bit.ly/umnydc"Details about the case are quite specific and the case report heralds from a town in Minnesota. It describes, in very specific detail, the management of a patient who presented to the emergency room in shock from cardiac tamponade after a catheter ablation procedure for right ventricular outflow tract tachycardia.Is this unique case report HIPAA compliant?I would say, according to our current definition of HIPAA's "personal health information," such a case report is not HIPAA compliant. Nor could such a case be mentioned on a blog, for that matter, even though it presents important information for people dealing with these patients.There is an important quality-of-care role in telling these clinical stories. In fact, HIPAA states there are just "18 little rules" that doctors are supposed to follow when they report important clinical cases. But details about cases may need to be very specific. Specific case reports can bring important specific clinical details to the attention of the medical community. For instance, if doctors had not been willing to describe several cases of pulmonary vein stenosis or two cases of esophageal perforation in a major medical journal years ago, how many more people might have been injured as a result?But there's problem giving such details about clinical details about patient cases: "the small cell problem": "Clinicians should be sensitive to the 'small cell problem': the existence of individuals with such unique or unusual diagnoses or illnesses, that it might be possible for others (or patients and families themselves) to identify the individuals in case reports or medical text books based upon limited information, such as state or city of residence, age and diagnosis."The "small cell" problem violates HIPAA and HIPAA means business: millions of dollars of business that gets released in press releases from the Department of Health and Human Services when they catch their prey.But doctors should not be afraid of publishing case reports especially since there are good reasons for them clinically. Further, when doctors make good faith efforts to conceal patient's personal information in those reports, they should not be subject to threats of HIPAA's "small cell" problem. Simply put: the "small cell" problem is HIPAA's, not the doctors'. Extending the definition of personal health information as defined by HIPAA to include "any other unique identifying characteristic" about a patient's case limits doctors' ability to improve care to our patients while greatly increasing our legal culpability for that effort.This post by Westby Fisher, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.
- A pox on your house? How fighting one disease brought bac... [Editor's note: This post was originally published November 5, 2009.]Some were surprised to read that after a pro basketball player swatted a bat out of the air, he had to have rabies vaccinations.This is not a surprise to many medical folks who have had to give rabies prophylaxis after bat exposures. Most of the few human rabies cases in the U.S. are transmitted by bats, although raccoons are more often diagnosed with the disease. Because rabies is fairly easy to transmit and nearly always fatal to humans, we are very aggressive about prevention. Rabid wild animals can have unusually aggressive behavior and can transmit rabies to humans and to their pets. With human populations mixing more and more freely with wild animal populations, the risk of rabies exposures increases. We're obviously not about to hold down every wild raccoon and vaccinate them, but humans, being rather clever animals, have found a way to vaccinate animals in high-risk areas.One program aims to create a "vaccine barrier" in the Appalachians by dropping oral rabies vaccines into these areas either by plane or by hand. The program is aimed primarily at raccoons but other animals are affected as well. The vaccine itself is fiendishly clever, but, as the CDC reports, is not without some unintended results.The vaccine was created by taking a glycoprotein antigen from the rabies virus and inserting it into Vaccinia virus, the same one used for smallpox inoculation. Further explanation requires a historical digression.Smallpox killed and disfigured millions of people around the world until its eradication in 1979 through a massive vaccination program. It is unclear when parts of Asia and Asia Minor began using immunotherapy to prevent smallpox deaths, but in the early 18th century, Lady Mary Worthley Montagu, an English aristocrat stationed in Istanbul, made note of the practice and brought it back to England.In these pre-vaccination days, smallpox pustules would be lanced, and their contents inserted into the skin of healthy people, producing a (hopefully) minor, localized infection which would then protect people from severe smallpox infection. Smallpox inoculation saved many lives but was not without risk. Later in the century, Edward Jenner developed the practice that ultimately replaced it: vaccination. This practice was based on the observation that milkmaids previously infected with cowpox ("vaccinia"), a usually-minor infection in humans, were relatively safe from smallpox. Two hundred years later, smallpox was gone.Vaccinia is not one of the safer vaccines. In people with defective immune systems, the normally mild infection can be severe, so eradicating smallpox not only saved people from smallpox but from needing the vaccine (it is still used in specialized settings such as the military). But vaccinia has not outlived its usefulness.How do you vaccinate millions of wild animals? Most vaccines must be injected, but there are exceptions, such as the human oral polio vaccine. In this case, a little genetic engineering convinced vaccinia to produce an important rabies antigen. When eaten, the virus in taken up in the lymphatic tissue in the throat, and immunity to rabies develops. The vaccinia infection caused by the vaccine is usually mild and transient.So in areas where it's needed, little ketchup package-shaped vaccines are dropped from planes or spread by hand. They are wrapped in tasty fishmeal, and animals readily bite into them. But raccoons aren't the only curious animals out there. Dogs are pretty curious, too. Because this vaccine contains a live virus, the CDC maintains a surveillance system to watch for human infections. They found one.A woman in Pennsylvania was out picking berries when her dog brought her a vaccine packet it had found. Some of the vaccine material dripped on to her hands which had been abraded by the berry brambles. She was perfectly inoculated by the special vaccinia virus. In most people, this would only be of passing interest, but the woman suffers from inflammatory bowel disease and takes powerful drugs to suppress her immune system. Within four days of exposure, she had pox on her hand.She sought help even before she developed the rash so doctors were able to track her disease carefully. Unlike normal patients, she did not develop antibodies to fight her infection, and it started to spread. Her immunosuppressive medications were stopped, and she was treated with specific immunoglobulin treatments and recovered without lasting ill effects.This case of human vaccinia infection is notable for it's rarity. Only one other person has ever developed an infection from the vaccine. The rabies problem is real, and this is a fascinating solution, but as the CDC points out, education needs to improve in areas where the vaccine is used.This one case walks us from Lady Worthley Montagu's 18th century observations, to Jenner's discovery, the eradication of smallpox, and the co-opting of the same organism via recombinant DNA techniques to help fight an entirely different disease. Science doesn't get any more interesting than this.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.
- The doctor and the orthodontist I took my daughter to the orthodontist last week to get braces. (She chose purple.)There's a lot about the process that seems better than when I was a kid. Mostly, it's that instead of having to slide brackets around each of your teeth (yishk!) the orthodontist just paints a special glue on the enamel and places the brace on the front of each tooth. Kids get to pick the color of their braces now, introducing some degree of choice (and therefore control) into what amounts to a victimization of one's oral cavity.What really stunned me, though, was the way that her orthodontist organized his practice.I've written before about the concept of patient-centered medical homes," [PCMH] a high-minded concept in which patients see a doctor or her associates whenever necessary, and all information is seamlessly inside a electronic medical record so any and all providers are able to deliver timely, safe, effective, high-quality care.It's an idea that is central to health care reform, and seen as a way in which we can contain costs. [Of course one of the big problems with this concept is that patients often don't understand the name. Survey data shows that there are loads of misconceptions about what a PCMH actually is. Here is one funny look at this phenomenon.]My daughter's orthodontist is part of a three-person practice. But for each orthodontist, there are three hygienist/techs and at least one office staff member handling billing, care coordination, and administrative issues like computers.This sounds pretty personnel-heavy, but let me assure you there was constant motion and therefore constant productivity.In the hour that it took for my daughter to have her braces applied, there were four different patients seen in the chair next to her, by three different techs and two of the orthodontists.The examining suite was arranged with eight chairs in a semicircle, and each chair had a computer screen next to it so that the patient's parents could see their kids' X-rays, projections of what their jaws/teeth would look like during and after treatment, and get educational material. Of course, the techs and orthodontists used the system for entering patient data as well.In the center of the circle, tech/hygienists were troubleshooting, preparing trays for subsequent patients, discussing aspects of care, etc.The orthodontists (two present while I was there) literally sat on office chairs and swiveled from patient to patient, washing up copiously between each encounter, and leaving plenty of time to communicate with parents, and work phone calls in between patients.It was a tour de force.I was overwhelmed by the efficiency of it all, the professional nature of the encounter(s), and my daughter entering a rite of passage (and how brave she was!) in no particular order.How much does it cost?Well, like health insurance, our employee-benefit dental insurance defrayed a significant portion of the upfront cost. What our insurance didn't cover, we could have financed. We chose to pay the remainder in a lump sum so as not to incur interest on the debt.But like a capitation model, we've paid for the treatment. Under the contract we've signed, our daughter can visit the orthodontist 12 times, 24 times or more, however many it takes to get her teeth straight. I'm certain that at a practice like this one they know their business well enough that even with some unexpected hiccups, they will make money on most patients in the long run.And I'm OK with that. They are providing real value for our money. It goes beyond the "product." It encompasses the feeling that I got by participating in my daughter's care and seeing how the operation worked. Literally.Our experience there made me wonder why medicine can't be practiced this way.Medicine is too complicated. Our costs are too variable. Our practice flows are less predictable. We're not just focusing on one part of the body.But what's to stop us from, say, asking our patients with diabetes to come to group visits? They could be seen en masse for education and testing, and see the doctor for quick individual consultations about medication adjustment or the need for further consultation. All the providers (physicians, nurses, medical assistants, physician assistants, nurse practitioners, dietitians, etc.) could be practicing at the top of our licenses.At the orthodontist's office, the hygienists and techs all were involved in lab work, preparation, and direct patient care. No one's talents were going to waste by locking into one repetitive job description. I spoke with one hygienist, and she told me that she enjoyed the different roles in her job. And she felt empowered to make change or to let the orthodontists know if something wasn't working well. All in all, it seemed a pleasant work place with a real team atmosphere.I guess seeing it firsthand makes me realize that achieving a medical home model can be done in primary care. We just need our medical homes to be more like our orthodontic homes.Just ask my daughter. Luckily for her, with modern methods, there's no need for headgear anymore. (I never smiled when I had to wear this trap.)This post by John H. Schumann, 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.
AAFP News Now
- FPs Share Their Experiences With PCMH Pilot Projects In 2005, Tracy Hofeditz, M.D., stood at a crossroads. He'd been in a large group practice in Lakewood, Colo., for several years. But he increasingly found that the way he had to practice -- cramming maximum patients into each day -- was unsustainable and even degrading for him and his patients. Finally, he couldn't hack it anymore. He left his group practice and considered an attractive opportunity in another field. "Yet I was born and called to be a family physician," he says. "I also didn't want to abandon my patients. I was surprised at how valuable my relationship with them was to me."
- Kentucky FPs Join Fight to Make Pseudoephedrine Prescript... Sixteen state legislatures considered bills this year that would have made pseudoephedrine -- the key ingredient in methamphetamine -- a prescription drug. But, despite the escalating number of meth lab incidence nationwide and an estimated $23 billion a year spent on issues related to meth abuse, the measures failed in all 16 states. For one of those states, however, the battle is just beginning.
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- AAFP, TransforMED Combine Knowledge to Better Serve Members It was only seven years ago that the Future of Family Medicine report recommended that primary care in the United States adopt a new model of health care focused on creating a medical home for patients. The report also called for creation of a financially self-sustaining national resource center to provide support to FP practices as they transitioned to this new model of care.
- Family Medicine Residencies Battle Ailing Economies, Stat... Texas once served as an example of a state willing to make a solid investment in the production and recruitment of its family physician and primary care workforce. In fact, during the past few decades, the state had provided an increasing amount of money for family medicine residency programs through its Texas Higher Education Coordinating Board, which was created to support the recruitment and residency training of family physicians and other primary care physicians in the state. Two years ago, Texas established a physician loan repayment program that awarded as much as $160,000 during a four-year period to physicians who agreed to provide primary care services in designated health professional shortage areas.
- Organizations Call for Enhanced Collaboration in Labor, D... The AAFP, in collaboration with several other health care professional organizations, is calling for health care providers and administrators to better collaborate in efforts to curb infant mortality rates and improve labor and delivery outcomes in the United States. The Academy, together with the American Academy of Pediatrics; the American College of Nurse-Midwives; the American College of Obstetricians and Gynecologists; the American College of Osteopathic Obstetricians and Gynecologists; the Association of Women's Health, Obstetric and Neonatal Nurses; and the Society for Maternal-Fetal Medicine, issued a "call to action" on Nov. 30.
- Alcohol Screening Guide Helps FPs Target Teens Who May Ne... Alcohol is the drug most frequently used by teenagers in the United States. Underage drinking has long been an important issue for family physicians who care for these young patients, and many FPs deal with it on a daily basis in their practices. Now, however, the issue has grown even more significant, as so-called binge drinking has emerged as another common problem among teens. In response to this public health threat, the National Institute on Alcohol Abuse and Alcoholism and the American Academy of Pediatrics have developed a resource designed to prevent alcohol-related problems in teens before they start or to detect these problems at an early stage.
- News in Brief: Week of Nov. 28-Dec. 2 This roundup includes the following news briefs: Obama Administration Nominates Nurse to Succeed Berwick at CMS, System Facilitates Data-sharing Among Prescription Monitoring Programs, Application Deadline for Federal Loan Repayment Program Is Dec. 14, HHS Awards Money for State-based Insurance Exchanges, and NCQA Launches ACO Accreditation Program.
- People in the News/Awards -- November has learned of two AAFP members who received honors and awards this past month.
Journal of General Internal Medicine (Online First™)
- Factors Associated with Pneumonia Outcomes: A Nationwide ... Abstract BACKGROUND Pneumonia is the most common infectious cause of death worldwide. Over the last decade, patient characteristics and health care factors have changed. However, little information is available regarding systematically and simultaneously exploring effects of these changes on pneumonia outcomes. OBJECTIVES We used nationwide longitudinal population-based data to examine which patient characteristics and health care factors were associated with changes in 30-day mortality rates for pneumonia patients. DESIGN Trend analysis using multilevel techniques. SETTING General acute care hospitals throughout Taiwan. PARTICIPANTS A total of 788,011 pneumonia admissions. MEASUREMENTS Thirty-day mortality rates. Taiwan’s National Health Insurance claims data from 1997 to 2008 were used to identify the effects of patient characteristics and health care factors on 30-day mortality rates. RESULTS Male, older, or severely ill patients, patients with more comorbidities, weekend admissions, larger reimbursement cuts and lower physician volume were associated with increased 30-day mortality rates. Moreover, there were interactions between patient age and trend on mortality. CONCLUSIONS Male, older or severely ill patients with pneumonia have higher 30-day mortality rates. However, mortality gaps between elderly and young patients narrowed over time; namely, the decline rate of mortality among elderly patients was faster than that among young patients. Pneumonia patients admitted on weekends also have higher mortality rates than those admitted on weekdays. The mortality of pneumonia patients rises under increased financial strain from cuts in reimbursement such as the Balanced Budget Act in the United States or global budgeting. Higher physician volume is associated with lower mortality rates. Content Type Journal ArticleCategory Original ResearchPages 1-7DOI 10.1007/s11606-011-1932-1Authors Guann-Ming Chang, Department of Family Medicine, Cardinal Tien Hospital, New Taipei City, TaiwanYu-Chi Tung, Department of Healthcare Information and Management, Ming Chuan University, Room AA611, No. 5, De Ming Rd, Gui Shan District, Taoyuan County, 333 Taiwan Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
- Impact of Comorbidity on Mortality Among Older Persons wi... Abstract BACKGROUND Care for patients with advanced heart failure (HF) has traditionally focused on managing HF alone; however, little is known about the prevalence and contribution of comorbidity to mortality among this population. We compared the impact of comorbidity on mortality in older adults with HF with high mortality risk and those with lower mortality risk, as defined by presence or absence of a prior hospitalization for HF, respectively. METHODS This was a retrospective cohort study (2002–2006) of 18,322 age-matched and gender-matched Medicare beneficiaries. We used the baseline year of 2002 to ascertain HF hospitalization history, in order to identify beneficiaries at either high or low risk of future HF mortality. We calculated the prevalence of 19 comorbidities and overall comorbidity burden, defined as a count of conditions, among both high and low risk beneficiaries, in 2002. Proportional hazards regressions were used to determine the effect of individual comorbidity and comorbidity burden on mortality between 2002 and 2006 among both groups. RESULTS Most comorbidities were significantly more prevalent among hospitalized versus non-hospitalized beneficiaries; myocardial infarction, atrial fibrillation, kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and hip fracture were more than twice as prevalent in the hospitalized group. Among hospitalized beneficiaries, myocardial infarction, diabetes, COPD, CKD, dementia, depression, hip fracture, stroke, colorectal cancer and lung cancer were each significantly associated with increased hazard of dying (hazard ratios [HRs]: 1.16-1.93), adjusting for age, gender and race. The mortality risk associated with most comorbidities was higher among non-hospitalized beneficiaries (HRs: 1.32-3.78). CONCLUSIONS Comorbidity confers a significantly increased mortality risk even among older adults with an overall high mortality risk due to HF. Clinicians who routinely care for this population should consider the impact of comorbidity on outcomes in their overall management of HF. Such information may also be useful when considering the risks and benefits of aggressive, high-intensity life-prolonging interventions. Content Type Journal ArticleCategory Original ResearchPages 1-7DOI 10.1007/s11606-011-1930-3Authors Sangeeta C. Ahluwalia, Center for the Study of Healthcare Provider Behavior, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd. 111-G, Los Angeles, CA 90064, USACary P. Gross, Department of Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, USASarwat I. Chaudhry, Department of Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, USAYuming M. Ning, Program on Aging, Yale School of Medicine, New Haven, USALinda Leo-Summers, Program on Aging, Yale School of Medicine, New Haven, USAPeter H. Van Ness, Program on Aging, Yale School of Medicine, New Haven, USATerri R. Fried, Department of Internal Medicine, Section of Geriatrics, Yale School of Medicine, New Haven, USA Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
- Performance of Health Literacy Tests Among Older Adults w... ABSTRACT BACKGROUND Knowing a patient’s health literacy can help clinicians and researchers anticipate a patient’s ability to understand complex health regimens and deliver better patient-centered instructions and information. Poor health literacy has been linked with lower ability to function adequately in health care systems. OBJECTIVE We evaluated and compared three measures of health literacy and performance among older patients with diabetes. DESIGN Cross-sectional study utilizing in-person interviews conducted in participants’ homes. PARTICIPANTS A tri-ethnic sample (n = 563) of African American, American Indian, and white older adults with diabetes from eight counties in south-central North Carolina. MAIN MEASURE Participants completed interviews and health literacy assessments using the Short-Form Test of Functional Health Literacy in Adults (S-TOFHLA), the Rapid Estimates of Adult Literacy in Medicine Short-Form (REALM-SF), or the Newest Vital Signs (NVS). Scores for reading comprehension and numeracy were calculated. RESULTS Over 90% completed the S-TOFHLA numeracy and approximately 85% completed the S-TOFHLA reading and REALM-SF. Only 73% completed the NVS. The correlation of S-TOFHLA total scores with REALM-SF and NVS were 0.48 and 0.54, respectively. Age, gender, ethnic, educational and income differences in health literacy emerged for several instruments, but the pattern of results across the instruments was highly variable. CONCLUSIONS A large segment of older adults is unable to complete short-form assessments of health literacy. Among those who were able to complete assessments, the REALM-SF and NVS performed comparably, but their relatively low convergence with the S-TOFHLA raises questions about instrument selection when studying health literacy of older adults. Content Type Journal ArticleCategory Original ResearchPages 1-7DOI 10.1007/s11606-011-1927-yAuthors Julienne K. Kirk, Department of Family and Community Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1084, USAJoseph G. Grzywacz, Department of Family and Community Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1084, USAThomas A. Arcury, Department of Family and Community Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1084, USAEdward H. Ip, Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USAHa T. Nguyen, Department of Family and Community Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1084, USARonny A. Bell, Department of Epidemiology and Prevention, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USASantiago Saldana, Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USASara A. Quandt, Department of Epidemiology and Prevention, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
- Older Homeless Adults: Can We Do More? Older Homeless Adults: Can We Do More? Content Type Journal ArticleCategory EditorialsPages 1-2DOI 10.1007/s11606-011-1925-0Authors Margot Kushel, Division of General Internal Medicine, University of California San Francisco, San Francisco General Hospital, UCSF Box 1364, San Francisco, CA 94143, USA Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
- Providing Cancer Care: Individual or Team Sport? Providing Cancer Care: Individual or Team Sport? Content Type Journal ArticleCategory EditorialsPages 1-2DOI 10.1007/s11606-011-1922-3Authors Nancy L. Keating, Division of General Internal Medicine, Brigham and Women’s Hospital and Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USAJennifer L. Malin, West Los Angeles Veterans Affairs Medical Center, Los Angeles, CA, USA Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
- From the Editors’ Desk: Realizing the Dream: Mentorship... From the Editors’ Desk: Realizing the Dream: Mentorship in Academic Medicine Content Type Journal ArticlePages 1-2DOI 10.1007/s11606-011-1923-2Authors Mitchell D. Feldman, Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, 1545 Divisadero, San Francisco, CA 94143-0320, USA Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
- Depression and Anxiety Diagnoses Are Not Associated with ... Abstract Background Delays in care after abnormal cancer screening contribute to disparities in cancer outcomes. Women with psychiatric disorders are less likely to receive cancer screening and may also have delays in diagnostic resolution after an abnormal screening test. Objective To determine if depression and anxiety are associated with delays in resolution after abnormal mammograms and Pap tests in a vulnerable population of urban women. Design We conducted retrospective chart reviews of electronic medical records to identify women who had a diagnosis of depression or anxiety in the year prior to the abnormal mammogram or Pap test. We used time-to-event analysis to analyze the outcome of time to resolution after abnormal cancer screening, and Cox proportional hazards regression modeling to control for confounding. Participants Women receiving care in six Boston-area community health centers 2004–2005: 523 with abnormal mammograms, 474 with abnormal Pap tests. Results Of the women with abnormal mammogram and pap tests, 19% and 16%, respectively, had co-morbid depression. There was no difference in time to diagnostic resolution between depressed and not-depressed women for those with abnormal mammograms (aHR = 0.9, 95 CI 0.7,1.1) or Pap tests (aHR = 0.9, 95 CI 0.7,1.3). Conclusions An active diagnosis of depression and/or anxiety in the year prior to an abnormal mammogram or Pap test was not associated with a prolonged time to diagnostic resolution. Our findings imply that documented mood disorders do not identify an additional barrier to resolution after abnormal cancer screening in a vulnerable population of women. Content Type Journal ArticleCategory Original ResearchPages 1-6DOI 10.1007/s11606-011-1920-5Authors Andrea C. Kronman, Women’s Health Unit, Section of General Internal Medicine, Department of Medicine, and Women’s Health Interdisciplinary Research Center, Boston University School of Medicine, 801 Massachusetts Avenue, Suite 470, Boston, MA 02118, USAKaren M. Freund, Women’s Health Unit, Section of General Internal Medicine, Department of Medicine, and Women’s Health Interdisciplinary Research Center, Boston University School of Medicine, 801 Massachusetts Avenue, Suite 470, Boston, MA 02118, USATim Heeren, Department of Biostatistics, Boston University School of Public Health, Boston, MA, USAKristine A. Beaver, Women’s Health Unit, Section of General Internal Medicine, Department of Medicine, and Women’s Health Interdisciplinary Research Center, Boston University School of Medicine, 801 Massachusetts Avenue, Suite 470, Boston, MA 02118, USAMary Flynn, Women’s Health Unit, Section of General Internal Medicine, Department of Medicine, and Women’s Health Interdisciplinary Research Center, Boston University School of Medicine, 801 Massachusetts Avenue, Suite 470, Boston, MA 02118, USATracy A. Battaglia, Women’s Health Unit, Section of General Internal Medicine, Department of Medicine, and Women’s Health Interdisciplinary Research Center, Boston University School of Medicine, 801 Massachusetts Avenue, Suite 470, Boston, MA 02118, USA Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
- Measuring Pain Impact Versus Pain Severity Using a Numeri... Abstract Background Routine assessments of pain using an intensity numeric rating scale (NRS) have improved documentation, but have not improved clinical outcomes. This may be, in part, due to the failure of the NRS to adequately predict patients’ preferences for additional treatment. Objective To examine whether patients’ illness perceptions have a stronger association with patient treatment preferences than the pain intensity NRS. Design Single face-to-face interview. Participants Outpatients with chronic, noncancer, musculoskeletal pain. Main Measures Experience of pain was measured using 18 illness perception items. Factor analysis of these items found that five factors accounted for 67.1% of the variance; 38% of the variance was accounted for by a single factor labeled “pain impact.” Generalized linear models were used to examine how NRS scores and physical function compare with pain impact in predicting preferences for highly effective/high-risk treatment. Key Results Two hundred forty-nine subjects agreed to participate. Neither NRS nor functioning predicted patient preference (NRS: χ2 = 1.92, df = 1, p = 0.16, physical functioning: χ2 = 2.48, df = 1, p = 0.11). In contrast, pain impact was significantly associated with the preference for a riskier/more effective treatment after adjusting for age, comorbidity, efficacy of current medications and numeracy (χ2 = 4.40, df = 1, p = 0.04). Conclusions Tools that measure the impact of pain may be a more valuable screening instrument than the NRS. Further research is now needed to determine if measuring the impact of pain in clinical practice is more effective at triggering appropriate management than more restricted measures of pain such as the NRS. Content Type Journal ArticleCategory Original ResearchPages 1-6DOI 10.1007/s11606-011-1926-zAuthors Liana Fraenkel, VA CT Healthcare System, Yale University School of Medicine, New Haven, CT, USAPaul Falzer, VA CT Healthcare System, New Haven, CT, USATerri Fried, VA CT Healthcare System, Yale University School of Medicine, New Haven, CT, USAMinna Kohler, VA CT Healthcare System, Yale University School of Medicine, New Haven, CT, USAEllen Peters, Ohio State University, Columbus, OH, USARobert Kerns, VA CT Healthcare System, Yale University School of Medicine, New Haven, CT, USAHoward Leventhal, Rutgers, The State University of New Jersey, Newark, NJ, USA Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
- ‘The Body Gets Used to Them’: Patients’ Interpretat... Abstract BACKGROUND Interventions promoting evidence based antibiotic prescribing and use frequently build on the concept of antibiotic resistance but patients and clinicians may not share the same assumptions about its meaning. OBJECTIVE To explore patients’ interpretations of ‘antibiotic resistance’ and to consider the implications for strategies to contain antibiotic resistance. DESIGN Multi country qualitative interview study. PARTICIPANTS One hundred and twenty-one adult patients from primary care research networks based in nine European countries who had recently consulted a primary care clinician with symptoms of Lower Respiratory Tract Infection (LRTI). APPROACH Semi-structured interviews with patients following their consultation and subjected to a five-stage analytic framework approach (familiarization, developing a thematic framework from the interview questions and the themes emerging from the data, indexing, charting, and mapping to search for interpretations in the data), with local network facilitators commenting on preliminary reports. RESULTS The dominant theme was antibiotic resistance as a property of a ‘resistant human body’, where the barrier to antibiotic effectiveness was individual loss of responsiveness. Less commonly, patients correctly conceptualized antibiotic resistance as a property of bacteria. Nevertheless, the over-use of antibiotics was a strong central concept in almost all patients’ explanations, whether they viewed resistance as located in either the body or in bacteria. CONCLUSIONS Most patients were aware of the link between antibiotic use and antibiotic resistance. The identification of the misinterpretation of antibiotic resistance as a property of the human body rather than bacterial cells could inform clearer clinician–patient discussions and public health interventions through emphasising the transferability of resistance, and the societal contribution individuals can make through more appropriate antibiotic prescribing and use. Content Type Journal ArticleCategory Original ResearchPages 1-7DOI 10.1007/s11606-011-1916-1Authors Lucy Brookes-Howell, South East Wales Trials Unit (SEWTU), Department of Primary Care and Public Health, School of Medicine, Cardiff University, 7th floor Neuadd Meirionnydd, Heath Park, Cardiff, Wales, UKGlyn Elwyn, Department of Primary Care and Public Health, School of Medicine, Cardiff University, 3rd floor Neuadd Meirionnydd, Heath Park, Cardiff, Wales, UKKerenza Hood, South East Wales Trials Unit (SEWTU), Department of Primary Care and Public Health, School of Medicine, Cardiff University, 7th floor Neuadd Meirionnydd, Heath Park, Cardiff, Wales, UKFiona Wood, Department of Primary Care and Public Health, School of Medicine, Cardiff University, 3rd floor Neuadd Meirionnydd, Heath Park, Cardiff, Wales, UKLucy Cooper, Health Research, Institute of Psychology, Health & Society, University of Liverpool, 1st floor Waterhouse Buildings, 1-5 Brownlow Street, Liverpool, England, UKHerman Goossens, University of Antwerp-Campus, Drie Eiken, Vaccine & Infectious Disease Institute - Laboratory of Medical Microbiology, University Hospital Antwerp, Wilrijkstraat 10, Antwerp, Belgium BE 2650Margareta Ieven, University of Antwerp-Campus, Drie Eiken, Vaccine & Infectious Disease Institute - Laboratory of Medical Microbiology, University Hospital Antwerp, Wilrijkstraat 10, Antwerp, Belgium BE 2650Christopher C Butler, Department of Primary Care and Public Health, School of Medicine, Cardiff University, 3rd floor Neuadd Meirionnydd, Heath Park, Cardiff, Wales, UK Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
- The Relationship Between Distal and Proximal Colonic Neop... ABSTRACT OBJECTIVES To investigate the association between proximal colonic neoplasia and distal lesions as a function of the lesion type. The extent to which health, demographic, and study characteristics moderate this association was also examined. DATA SOURCES Google Scholar, Web of Science, Scopus, and PubMed. STUDY ELIGIBILITY CRITERIA Studies allowing the calculation of OR of proximal neoplasia (PN) and proximal advanced neoplasia (PAN) for distal hyperplastic polyps (HP), nonadvanced adenomas (NAA), adenomas (AD), and advanced neoplasia (AN); also, studies for which the proportions of subjects with isolated (i.e., not accompanied by distal lesions) PN (IPN) and PAN (IPAN) over the total number of subjects with PN or PAN could be calculated. STUDY APPRAISAL AND SYNTHESIS METHODS Thirty-two studies were included for calculating OR between proximal neoplasia and distal lesions and 40 studies for proportions of IPN and IPAN. Subgroup analyses were conducted for presence of symptoms, prevalence of PN and PAN, age, proportion of males, geographic region, study design, and demarcation point. RESULTS The association between distal lesions and proximal neoplasia increased with the severity of the distal lesions. Odds of PN were higher in subjects with HP compared to subjects with a normal distal colon. Odds of PN and PAN were higher in subjects with NAA, AD, and AN than in subjects with a normal distal colon. PAN were more strongly associated with distal lesions in asymptomatic populations, in young populations, and in populations with a low prevalence of PAN. In approximately 60% of the subjects with PN and PAN, these neoplasia were isolated. LIMITATIONS The present results may be affected by publication bias and dichotomization in the subgroup analyses. Limitations related to the individual studies include self-selection, lesion misclassification and misses, and technological advances leading to changes in the detection of lesions during the time span of the included studies. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS All types of distal lesions are predictive of PN. All types of distal neoplasia are predictive of PAN. The association between distal lesions and proximal neoplasia increases with the severity of the distal lesion. The association between distal lesions and proximal advanced neoplasia is stronger in low-risk groups as compared to high-risk groups. Content Type Journal ArticleCategory ReviewsPages 1-10DOI 10.1007/s11606-011-1919-yAuthors Dimitra Dodou, Department of BioMechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD Delft, The NetherlandsJoost C. F. de Winter, Department of BioMechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD Delft, The Netherlands Journal Journal of General Internal MedicineOnline ISSN 1525-1497Print ISSN 0884-8734
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- Happy Meal toys no longer free in San Francisco A new San Francisco law prevents fast-food restaurants from giving away toys in their kid's meals unless their food meets nutritional requirements.
- Homeless and HIV-positive An Atlanta addict and mother tells of her fall from a life with "everything I needed" as a youth to a cycle of addiction, drugs, homelessness and HIV.
- Florida city battles fear and denial Even in a city as big as Jacksonville, the stigma surrounding HIV/AIDS persists. Clinics change their names, patients hide diagnoses and experts fear it's only making the problem worse.
- Pastor fights stigma in rural town Brenda Byrth fights against fear, poor education and a lack of funding as she works to help people with HIV/AIDS in her community.
- Restless sleep? Maybe you're lonely Feeling isolated and disconnected from the people around you may keep you from getting a good night's sleep, even if you're not aware of it, a small new study suggests.
MedlinePlus Health News
- Cook It Right! Source: HealthDay - Related MedlinePlus Pages: Healthy Living, Nutrition
- FDA Approves First Generic Version of Cholesterol-Lowerin... Source: Food and Drug Administration Related MedlinePlus Page: Cholesterol
- Self-Monitoring of Blood Thinner May Halve Clot Risk But newer drugs may replace warfarin and the need for frequent blood tests, experts say Source: HealthDay Related MedlinePlus Pages: Bleeding Disorders, Blood Thinners
- Medicare to Cover Obesity Counseling, Screening The U.S. Medicare program for the elderly will cover counseling for obesity in an effort to reduce the condition that has reached epidemic proportions and leads to serious health problems.Source: Reuters Health Related MedlinePlus Pages: Medicare, Obesity
- When Cameras Are Watching, More Doctors Wash Up A new study found that more doctors and nurses washed their hands when video cameras were installed in every room in their unit and the staff was continuously informed about rates of hand-washing compliance.Source: Reuters Health Related MedlinePlus Pages: Germs and Hygiene, Health Facilities, Infectious Diseases
- Yoga May Ease Insomnia, Menopause Problems A couple of yoga sessions a week could help ease sleep problems and other effects of menopause, a small study suggests.Source: Reuters Health Related MedlinePlus Pages: Complementary and Alternative Medicine, Menopause, Sleep Disorders
- More Fruits And Veggies Don't Help Lung Disease Adding extra daily servings of fruits and vegetables didn't improve lung function or other markers of lung health in people with chronic obstructive pulmonary disease (COPD) in a new study from Northern Ireland. Source: Reuters Health Related MedlinePlus Pages: COPD (Chronic Obstructive Pulmonary Disease), Lung Diseases, Nutrition
- Scans May Discern Between Two Types of Dementia Alzheimer's and frontotemporal lobar degeneration can can be difficult to tell apart, researchers report Source: HealthDay Related MedlinePlus Pages: Alzheimer's Disease, Dementia, Diagnostic Imaging
- Clogged Arteries Pose Different Dangers for Men, Women Heart treatment might need to take gender into account, researcher saysSource: HealthDay Related MedlinePlus Pages: Coronary Artery Disease, Heart Disease in Women, Men's Health
- Lobular Breast Cancer Linked to Paternal Cancer History If dad had cancer and daughter has breast cancer, it tends to be in milk-producing lobules, study finds Source: HealthDay Related MedlinePlus Pages: Breast Cancer, Family History
Health Blog
- Must Hospital Cafeteria Food Be Healthful? Half of the 16 hospital cafeterias studied offered no healthful entrees.
- A.M. Vitals: Ranbaxy Launches Generic Lipitor in U.S. Also: Medicare counseling for weight loss; CSPI wants Quorn off the shelves; NYC makes aggressive recommendations for HIV treatment.
- Will the NBA Lockout Mean More Player Injuries? While some players likely maintained a high level of fitness during their extended break, others probably weren't so diligent.
- Countdown to Generic Lipitor: Whither the Uninsured? Pfizer will still be providing help to patients who can't afford the cholesterol-fighter, a company spokesman says.
- More States Move Closer to Health Insurance Exchanges Under the new health law, state-run exchanges will be launched in 2014, opening a marketplace where private insurers compete to offer health plans to the uninsured and to small businesses.
- A.M. Vitals: Most HIV Patients Lack Medications, Care Also: changes at the YMCA; FDA gives priority review status to Pfizer/Bristol-Myers Squibb drug; Cantor praises Tavenner.
- Countdown to Generic Lipitor: More Answers to Your Questions The timeline for switching to the generic varies by health plan, the WSJ reports.
- Countdown to Generic Lipitor: What’s In It for Drugstores? On the eve of tomorrow's launch of a generic Lipitor, most drug stores are taking a wait-and-see approach.
- A.M. Vitals: Are Drug Reps Eligible for Overtime Pay? Also: military veterans returning to college; getting smokers to quit; prison doctors paid to deliver mail in California.
- Midmorning Snacks Associated With Smaller Weight Loss Late-morning snackers tend to keep snacking throughout the day, presumably leading to a higher calorie intake.
National Institutes of Health (NIH) News Releases
- Mouse study explains bacterium's unique role in periodont... Scientists say they have solved in mice the mystery of how an unusual bacterium can trigger the common dental condition periodontitis while residing in low numbers in the space between tooth and gum.
- NIH nurse practitioner chosen for Excellence in Nursing A... Nancy Munro, an acute care nurse practitioner at the National Institutes of Health Clinical Center, is one of 10 recipients of Washingtonian magazine's 2011 Excellence in Nursing Award.
- Neurons grown from skin cells may hold clues to autism Potential clues to how autism miswires the brain are emerging from a study of a rare, purely genetic form of the disorders that affects fewer than 20 people worldwide.
- Training peers improves social outcomes for some kids wit... Children with autism spectrum disorder (ASD) who attend regular education classes may be more likely to improve their social skills if their typically developing peers are taught how to interact with them than if only the children with ASD are taught such skills.
- NIH answers call to streamline technology transfer process The National Institutes of Health is launching the electronic Research Materials catalogue (eRMa) to streamline the federal government's technology transfer process. This project addresses one of the important directives in a Presidential memorandum related to the commercialization of federal research and support for high-growth business potential. eRMa was designed and developed by the Office of Technology Transfer (OTT) at NIH with support from the NIH's National Cancer Institute Center for Cancer Research.
- NIH Discontinues Tenofovir Vaginal Gel in 'VOICE' HIV Pre... A large-scale clinical trial evaluating whether daily use of an antiretroviral-containing oral tablet or vaginal gel can prevent HIV infection in women is being modified because an interim review found that the gel, an investigational microbicide, was not effective among study participants.
- Cholesterol levels elevated in toddlers taking anti-HIV d... Toddlers receiving anti-HIV drugs have higher cholesterol levels, on average, than do their peers who do not have HIV, according to researchers at the National Institutes of Health and other institutions.
- NIH researchers identify key proteins of inner ear transd... National Institutes of Health-funded researchers have identified two proteins that may be the key components of the long-sought after mechanotransduction channel in the inner ear -- the place where the mechanical stimulation of sound waves is transformed into electrical signals that the brain recognizes as sound.
- COPD awareness continues to rise, new NIH survey finds Awareness of COPD (chronic obstructive pulmonary disease), the nation’s third leading killer, continues to rise in the United States, according to the results of a Web-based survey released today by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health.
- NIH-commissioned Census Bureau report describes oldest Am... In 1980, there were 720,000 people aged 90 and older in the United States. In 2010, there were 1.9 million people aged 90 and older; by 2050, the ranks of people 90 and older may reach 9 million, according to a report from the U.S. Census Bureau, commissioned by the National Institute on Aging (NIA) at the National Institutes of Health.
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
- The Checklist: How to stay healthy in December A gift to yourselfOne of the best ways to avoid gaining weight during the holiday eating season is to ramp up your exercise regimen. Yeah, right. Chalene Johnson knows it’s hard to squeeze exercise into your December schedule. But she’s convinced that even the most overwhelmed among us can make it happen. Read full article >>
- Vegan, vegetarian, gluten-free? You can still enjoy Thank... Years ago, my husband and I hosted a holiday party. We thought we had put together a nice array of food. But midway through I noticed a guest whom I hadn’t known very long surveying the spread with skepticism. Turned out she was a vegetarian, and, to my dismay, our holiday table had little to offer her. Read full article >>
- Coffee isn’t always bad for you Before I sat down to write this column, I zipped into the Dunkin’ Donuts drive-through to get a cup of iced black coffee, my favorite fuel. I’ve been drinking coffee since I was a toddler, when my folks would allow me to add milk and sugar to the dregs in their yellow plastic mugs and sip it down. Drinking coffee in college made me feel sophisticated; pots of strong brew kept me awake through the writing of my master’s thesis and hundreds of other documents. Read full article >>
- No dinner for Max? Depends on what he’s had to eat. The night Max wore his wolf suit and made mischief of one kind and another, his mother called him “WILD THING!” and Max said, “I’LL EAT YOU UP!,” and was sent to bed without eating anything. I have read Maurice Sendak’s book “Where the Wild Things Are” to my kids dozens of times. But I never stopped to think about what it means to send a kid to bed without eating, especially as a punishment for making mischief. Read full article >>
- Washington Sports Clubs launch exercise hotline for Thank... Befuddled home cooks all know to dial 1-800-BUTTERBALL when they have trouble taming their turkeys. But for many of us, the problem with Thanksgiving isn’t stuffing your bird — it’s stuffing yourself. So Washington Sports Clubs, along with its sister companies in New York, Boston and Philadelphia, is launching another hotline: 1-855-I-AM-FULL. Live operators will be available between 3 p.m. Wednesday until 11:59 p.m. Friday to help callers navigate the sea of gravy boats and strained relationships that can contribute to holiday weight gain. (And they’ll sweeten the deal by offering a free one-week gym pass.) Read full article >>
- Flag football: It’s the girls’ turn to play Last Thanksgiving Day, when 31.9 million people watched the New Orleans Saints play the Dallas Cowboys, 10.75 million of them were women. Overall, 44 percent of the National Football League’s fans are women. If you follow the sport, this is no revelation. The football widow is an anachronism; girls and women populate stadiums and sports bars, and have for years. In a recent Washington Post survey of D.C. sports fans, 53 percent of this area’s women said they care about the NFL, and 25 percent said they care “a great deal.” Read full article >>
- D.C.’s fitness scene makes room for ballet-inspired exe... Ever heard the one about the woman who walks into a barre? If not, that’s about to change as the city’s fitness scene makes room for ballet-inspired exercise classes. That doesn’t mean it’s time to dust off your old tutu. These lessons aren’t designed to land you a starring role in “The Nutcracker,” but rather to help you look like you could by borrowing dancers’ strengthening and stretching techniques — while using their favorite prop. Read full article >>
- Campaign encourages older Americans to start exercising Some things should go without saying. But sometimes we need to say them anyway. Here are two: You can’t stop exercising as you grow older. And if you’re 50 or so, and you’ve never adopted a fitness regimen, you’d better start. Both ideas seem so blindingly obvious, so utterly axiomatic for the self-involved baby boom generation of which I am part, that I’m still not sure why anyone needs to be reminded. But the numbers tell a different story. Read full article >>
- Food in school and after-school snacks: What’s in, what... Five fast after-school snacks There’s some debate over whether kids need to snack as often as they do. But kids don’t care about debates: When they get home from school, they’re ravenous and ready to eat. Here’s a week’s worth of quick and healthful snack ideas, courtesy of Marisa Moore, registered dietitian and a spokeswoman for the American Dietetic Association. Read full article >>
- Traffic science struggles to keep cars flowing on highway... Traffic science is one of those disciplines that seems permanently poised on the verge of a breakthrough. Professional journals regularly publish promising research, and the press trumpets their importance. In 1999, The Post reported that scientists had gathered at Los Alamos National Laboratory in New Mexico to solve our national traffic problem — just as an earlier generation of physicists had done to build the atomic bomb. And yet driving on the Beltway is still about as enjoyable as cleaning out your ears with a lemon reamer. Read full article >>
American Medical News
- Patients see health system as broken, but their own cover... A Gallup Poll says there could be political reasons for the fluctuation in views.
- Fraud hunt expected to save Medicare, Medicaid $25 billion A 2011 report to Congress highlights HHS Office of Inspector General work that has led to 184 convictions.
- New York health plans ordered to issue rebates on premiums Failing to meet an 82% minimum medical-loss ratio means that 11 insurers owe customers a total of $114.5 million.
- Iowa nurses not trained to oversee fluoroscopy, judge rules Physicians score a court victory after a rule allowing advanced registered nurse practitioners to supervise the radiological procedure is reversed.
- More patients seeing only allied health workers A CDC report is the latest to show the growing presence of nonphysician clinicians.
- Avoiding alcohol in adolescence may reduce breast cancer ... A study says girls with a family history of the illness doubled their risk of benign breast disease if they drank regularly as a teenager.
- AMA delegates detail steps to confront national drug shor... The AMA house backs such recommendations as mandating public notification of market withdrawals up to a year in advance.
- 3% tax withholding on Medicare pay repealed The IRS regulation, set to take effect in 2013, was designed to target delinquent government contractors but would have affected some Medicare physician payments.
- Medicare demonstration projects: From idea to implementation Many Medicare demos never survive tryouts, but enough have made the cut that the process might be integral to a payment system overhaul.
- Medicare RACs to conduct prepayment reviews for doctors, ... The Obama administration aims to prevent improper payments, but physician and hospital organizations are concerned that the audits will create more administrative work.
FOXNews.com
- Study Finds Afternoon Vaccinations Are Best The next time your baby is scheduled to receive a vaccination, you may want to consider booking the appointment in the afternoon
- Avoiding Weight Gain During the Holidays One of the most difficult times of the year for those trying to lose weight is the holiday season. The good news is that with a little foresight, those holiday pounds can be easily avoided while still enjoying yourself
- Customers Hurt by Syringes Found in Clothes at Georgia Wa... At least two people were hurt after four syringes were found hidden in bras, kids pajamas and other items of clothing at a Walmart store in Georgia
- Fight Against AIDS Faces New Financial Struggles Worldwide, we’ve made huge strides in the past 20 years in the fight against AIDS. But a major funding crisis threatens to impede—or even set back—that progress
- Supplements Everyone Should Consider Taking If you aren’t getting the vitamins and minerals your body needs from the foods you eat, it’s time to consider taking a supplement
- Corporate Competitions Offer Employees Incentives to Lose... Is corporate America taking a page from The Biggest Loser? You bet. In an effort to reduce health care costs, a growing number of companies are offering cash to overweight workers who lose weight
- Swearing May Help Ease Pain, Study Says Uttering expletives can help people cope with pain in the short-term, but is less effective if a person curses often, according to a new study
- Inspector Highlights Psych Drug Use Among Elderly Government inspectors told lawmakers Wednesday that Medicare officials need to do more to stop doctors from prescribing powerful psychiatric drugs to nursing home patients with dementia, an unapproved practice that has flourished despite repeated government warnings
- FDA Confirms Approves Ranbaxy's Generic Lipitor The U.S. Food and Drug Administration confirmed on Wednesday that it had given approval to Ranbaxy Laboratories Ltd to make the first generic version of the cholesterol-lowering drug Lipitor
- Diabetes Breakthrough Stalled in Safety Debate It's a dream of medical science that looks tantalizingly within reach: the artificial pancreas, a potential breakthrough treatment for the scourge of type 1 diabetes
CBC | Health News
- U.S. makes AIDS day $50M funding pledge U.S. President Barack Obama announced a deeper U.S. commitment to combatting the pandemic of AIDS, declaring: "We can beat this disease."
- B.C. eating disorder patients denied treatment At least a dozen adult patients with eating disorders have been discharged from a B.C. treatment program despite failing health, CBC News has learned.
- Health officials affirm chronic doctor shortage Windsor-Essex is still suffering from a chronic doctor shortage and should still be pursuing physician recruitment, says Gary Switzer, CEO of the Erie-St. Clair LHIN.
- Eastern Health promising to change hospital parking system Eastern Health says it plans to introduce a 'pay-as-you-go' system that it hopes will reduce complaints about parking at hospitals in St. John's.
- New hip implants may not be better Newer hip implants seem no better than traditional types of implants, a new review of research concludes.
- ANALYSIS | Health Canada drug approval policy lacks key p... Health Canada's inability to demand drug safety updates has drawn concern from the auditor general - and is particularly important for the growing list of drugs with only conditional approval.
- Is medicine feminized but sexist? Is medicine a woman's world, asks a British medical journal that questions whether the rising number of women in medicine is leading to overfeminization of the profession.
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
- Toothache lawsuit may stifle medical gag orders A Maryland man who had a bad toothache has filed a class-action lawsuit against his New York dentist after she required him to sign a contract promising not to trash-talk her online — and then fined him thousands of dollars trying to enforce it.
- Double whammy of setbacks cripple war on AIDS World AIDS Day is about recognizing how far we’ve come -- and how far we still have to go -- in the fight against a plague that has infected 60 million people and killed half of them. But today, now 30 years into the epidemic, a series of setbacks threatens to dash hopes for the goal of an “AIDS-free generation.”
- Moms multitask way more than dads - and hate it Working moms multitask far more than working dads and feel stressed out by it, while dads often enjoy it, a new study finds.
- FDA offers new guidance for artificial pancreas The FDA issued new guidelines on Thursday for the development of a potentially revolutionary device to treat type 1 diabetes that will give manufacturers "maximum flexibility" in getting it to U.S. patients.
- Why some see the face of Jesus in their toast There’s a long history of people finding meaning in mundane objects. And scientists now say they know why this happens -- and how it works.
- Thanksgiving eve food recalls raise questions Recalls of two iconic holiday foods — dried cranberries and canned pumpkin — on the night before Thanksgiving are raising eyebrows about the way some companies notify consumers about problems.
- High levels of arsenic found in fruit juice The apple and grape juice your kids are drinking may have arsenic at levels high enough to increase their risk of cancer and other chronic diseases, according to a new study by Consumer Reports.
- Dangerous beauty: FDA talks tainted makeup You might know and follow all the rules to keep your cosmetics safe. But what if your beauty product is contaminated before you even open the packaging? On Wednesday, the U.S. Food and Drug Administration is holding a public meeting examining safety issues in cosmetics.
- When cameras are watching, more docs wash up The number of doctors and nurses who washed their hands immediately after entering a patient's room shot from 7 to 88 percent when video cameras were installed in every room in their unit and the staff was continuously informed about hand-washing rates.
- NYC to offer AIDS drugs to early-diagnosed HIV patients City health officials said Thursday they are recommending that any person living with HIV be offered AIDS drugs as soon as they are diagnosed with the virus, an aggressive move that has been shown to prolong life and stem the spread of the disease.
WSJ.com: Health
- Generic Lipitor Goes on Sale This Week: A Users' Guide Generic versions of cholesterol-drug Lipitor can go on sale this week. Many patients look forward to the lower copayments that will bring. Others are concerned what the switch might mean for their health. A guide for consumers.
- Ranbaxy to Share Lipitor Profits Ranbaxy Laboratories surprised investors when it said it would share with Teva Pharmaceutical Industries profits from six months of exclusive sales of a copy of Pfizer's blood cholesterol-lowering Lipitor in the U.S.
- Icahn Pushes WebMD on Dutch Tender Offer Carl Icahn is pushing online health-information provider WebMD to spend up to $1 billion to buy back its shares through a Dutch tender offer.
- 'Quorn' Meat Substitute Fires Up Food Activist The Center for Science in the Public Interest sent a letter to the FDA last month asking that the agency remove Quorn, a popular meat substitute, from store shelves, saying it carries a risk of severe allergic reaction. The maker says very few people are sensitive to it.
- Jitters Over New GMAT Anxious business-school applicants have something to add to their to-do list: preparation for the new "integrated reasoning" section of the GMAT.
- Most HIV Patients Lack Needed Care Nearly three out of four people in the U.S. with HIV aren't getting enough medicine or regular care to stay healthy or prevent themselves from transmitting the virus to others, according to a new study.
- UnitedHealth Targets Double-Digit Growth UnitedHealth Group is targeting long-term earnings growth in a double-digit range as it aims to expand its Optum health-care-services business.
- Anticlotting Drug to Get Speedy FDA Review In another victory for an anticlotting drug co-developed by Bristol-Myers Squibb and Pfizer, U.S. regulators agreed to a speedy review of the companies' application to market it.
- Watson Wins FDA Approval for Contraceptive Watson Pharmaceuticals was granted Food and Drug Administration approval for its generic version of Bayer's Yaz birth-control pill.
- Tricking the Eye to Keep From Heaping Plates A new study suggests serving size can be affected by the colors of the dinnerware and tablecloth.
PLoS Medicine: New Articles
- Voluntary Medical Male Circumcision: An Introduction to t... by Catherine Hankins, Steven Forsythe, Emmanuel Njeuhmeli Scaling up voluntary medical male circumcision (VMMC) for HIV prevention is cost saving and creates fiscal space in the future that otherwise would have been encumbered by antiretroviral treatment costs. An investment of US$1,500,000,000 between 2011 and 2015 to achieve 80% coverage in 13 priority countries in southern and eastern Africa will result in net savings of US$16,500,000,000. Strong political leadership, country ownership, and stakeholder engagement, along with effective demand creation, community mobilisation, and human resource deployment, are essential. This collection of articles on determining the cost and impact of VMMC for HIV prevention signposts the way forward to scaling up VMMC service delivery safely and efficiently to reap individual- and population-level benefits.
- Voluntary Medical Male Circumcision: A Framework Analysis... by Kim E. Dickson, Nhan T. Tran, Julia L. Samuelson, Emmanuel Njeuhmeli, Peter Cherutich, Bruce Dick, Tim Farley, Caroline Ryan, Catherine A. Hankins Background Following confirmation of the effectiveness of voluntary medical male circumcision (VMMC) for HIV prevention, the World Health Organization and the Joint United Nations Programme on HIV/AIDS issued recommendations in 2007. Less than 5 y later, priority countries are at different stages of program scale-up. This paper analyzes the progress towards the scale-up of VMMC programs. It analyzes the adoption of VMMC as an additional HIV prevention strategy and explores the factors may have expedited or hindered the adoption of policies and initial program implementation in priority countries to date. Methods and Findings VMMCs performed in priority countries between 2008 and 2010 were recorded and used to classify countries into five adopter categories according to the Diffusion of Innovations framework. The main predictors of VMMC program adoption were determined and factors influencing subsequent scale-up explored. By the end of 2010, over 550,000 VMMCs had been performed, representing approximately 3% of the target coverage level in priority countries. The “early adopter” countries developed national VMMC policies and initiated VMMC program implementation soon after the release of the WHO recommendations. However, based on modeling using the Decision Makers' Program Planning Tool (DMPPT), only Kenya appears to be on track towards achievement of the DMPPT-estimated 80% coverage goal by 2015, having already achieved 61.5% of the DMPPT target. None of the other countries appear to be on track to achieve their targets. Potential predicators of early adoption of male circumcision programs include having a VMMC focal person, establishing a national policy, having an operational strategy, and the establishment of a pilot program. Conclusions Early adoption of VMMC policies did not necessarily result in rapid program scale-up. A key lesson is the importance of not only being ready to adopt a new intervention but also ensuring that factors critical to supporting and accelerating scale-up are incorporated into the program. The most successful program had country ownership and sustained leadership to translate research into a national policy and program. Please see later in the article for the Editors' Summary
- What Research Is Needed to Stop TB? Introducing the TB Re... by Christian Lienhardt, Marcos Espinal, Madhukar Pai, Dermot Maher, Mario C. Raviglione
- Voluntary Medical Male Circumcision: Modeling the Impact ... by Emmanuel Njeuhmeli, Steven Forsythe, Jason Reed, Marjorie Opuni, Lori Bollinger, Nathan Heard, Delivette Castor, John Stover, Timothy Farley, Veena Menon, Catherine Hankins Background There is strong evidence showing that voluntary medical male circumcision (VMMC) reduces HIV incidence in men. To inform the VMMC policies and goals of 13 priority countries in eastern and southern Africa, we estimate the impact and cost of scaling up adult VMMC using updated, country-specific data. Methods and Findings We use the Decision Makers' Program Planning Tool (DMPPT) to model the impact and cost of scaling up adult VMMC in Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province in Kenya. We use epidemiologic and demographic data from recent household surveys for each country. The cost of VMMC ranges from US$65.85 to US$95.15 per VMMC performed, based on a cost assessment of VMMC services aligned with the World Health Organization's considerations of models for optimizing volume and efficiencies. Results from the DMPPT models suggest that scaling up adult VMMC to reach 80% coverage in the 13 countries by 2015 would entail performing 20.34 million circumcisions between 2011 and 2015 and an additional 8.42 million between 2016 and 2025 (to maintain the 80% coverage). Such a scale-up would result in averting 3.36 million new HIV infections through 2025. In addition, while the model shows that this scale-up would cost a total of US$2 billion between 2011 and 2025, it would result in net savings (due to averted treatment and care costs) amounting to US$16.51 billion. Conclusions This study suggests that rapid scale-up of VMMC in eastern and southern Africa is warranted based on the likely impact on the region's HIV epidemics and net savings. Scaling up of safe VMMC in eastern and southern Africa will lead to a substantial reduction in HIV infections in the countries and lower health system costs through averted HIV care costs. Please see later in the article for the Editors' Summary.
- Voluntary Medical Male Circumcision: Logistics, Commoditi... by Dianna Edgil, Petra Stankard, Steven Forsythe, Dino Rech, Kristin Chrouser, Tigistu Adamu, Sameer Sakallah, Anne Goldzier Thomas, Jennifer Albertini, David Stanton, Kim Eva Dickson, Emmanuel Njeuhmeli Background The global HIV prevention community is implementing voluntary medical male circumcision (VMMC) programs across eastern and southern Africa, with a goal of reaching 80% coverage in adult males by 2015. Successful implementation will depend on the accessibility of commodities essential for VMMC programming and the appropriate allocation of resources to support the VMMC supply chain. For this, the United States President’s Emergency Plan for AIDS Relief, in collaboration with the World Health Organization and the Joint United Nations Programme on HIV/AIDS, has developed a standard list of commodities for VMMC programs. Methods and Findings This list of commodities was used to inform program planning for a 1-y program to circumcise 152,000 adult men in Swaziland. During this process, additional key commodities were identified, expanding the standard list to include commodities for waste management, HIV counseling and testing, and the treatment of sexually transmitted infections.The approximate costs for the procurement of commodities, management of a supply chain, and waste disposal, were determined for the VMMC program in Swaziland using current market prices of goods and services.Previous costing studies of VMMC programs did not capture supply chain costs, nor the full range of commodities needed for VMMC program implementation or waste management. Our calculations indicate that depending upon the volume of services provided, supply chain and waste management, including commodities and associated labor, contribute between US$58.92 and US$73.57 to the cost of performing one adult male circumcision in Swaziland. Conclusions Experience with the VMMC program in Swaziland indicates that supply chain and waste management add approximately US$60 per circumcision, nearly doubling the total per procedure cost estimated previously; these additional costs are used to inform the estimate of per procedure costs modeled by Njeuhmeli et al. in “Voluntary Medical Male Circumcision: Modeling the Impact and Cost of Expanding Male Circumcision for HIV Prevention in Eastern and Southern Africa.” Program planners and policy makers should consider the significant contribution of supply chain and waste management to VMMC program costs as they determine future resource needs for VMMC programs. Please see later in the article for the Editors' Summary
- Voluntary Medical Male Circumcision: Translating Research... by Zebedee Mwandi, Anne Murphy, Jason Reed, Kipruto Chesang, Emmanuel Njeuhmeli, Kawango Agot, Emma Llewellyn, Charles Kirui, Kennedy Serrem, Isaac Abuya, Mores Loolpapit, Regina Mbayaki, Ndungu Kiriro, Peter Cherutich, Nicholas Muraguri, John Motoku, Jack Kioko, Nancy Knight, Naomi Bock Since the World Health Organization and the Joint United Nations Programme on HIV/AIDS recommended implementation of medical male circumcision (MC) as part of HIV prevention in areas with low MC and high HIV prevalence rates in 2007, the government of Kenya has developed a strategy to circumcise 80% of uncircumcised men within five years. To facilitate the quick translation of research to practice, a national MC task force was formed in 2007, a medical MC policy was implemented in early 2008, and Nyanza Province, the region with the highest HIV burden and low rates of circumcision, was prioritized for services under the direction of a provincial voluntary medical male circumcision (VMMC) task force. The government's early and continuous engagement with community leaders/elders, politicians, youth, and women's groups has led to the rapid endorsement and acceptance of VMMC. In addition, several innovative approaches have helped to optimize VMMC scale-up. Since October 2008, the Kenyan VMMC program has circumcised approximately 290,000 men, mainly in Nyanza Province, an accomplishment made possible through a combination of governmental leadership, a documented implementation strategy, and the adoption of appropriate and innovative approaches. Kenya's success provides a model for others planning VMMC scale-up programs.
- Quality of Maternal Health Care: A Call for Papers for a ... by Samantha R. Lattof, Mary Nell Wegner, Ana Langer, and the PLoS Medicine Editors
- Voluntary Medical Male Circumcision: Matching Demand and ... by Hally R. Mahler, Baldwin Kileo, Kelly Curran, Marya Plotkin, Tigistu Adamu, Augustino Hellar, Sifuni Koshuma, Simeon Nyabenda, Michael Machaku, Mainza Lukobo-Durrell, Delivette Castor, Emmanuel Njeuhmeli, Bennett Fimbo The government of Tanzania has adopted voluntary medical male circumcision (VMMC) as an important component of its national HIV prevention strategy and is scaling up VMMC in eight regions nationwide, with the goal of reaching 2.8 million uncircumcised men by 2015. In a 2010 campaign lasting six weeks, five health facilities in Tanzania's Iringa Region performed 10,352 VMMCs, which exceeded the campaign's target by 72%, with an adverse event (AE) rate of 1%. HIV testing was almost universal during the campaign. Through the adoption of approaches designed to improve clinical efficiency—including the use of the forceps-guided surgical method, the use of multiple beds in an assembly line by surgical teams, and task shifting and task sharing—the campaign matched the supply of VMMC services with demand. Community mobilization and bringing client preparation tasks (such as counseling, testing, and client scheduling) out of the facility and into the community helped to generate demand. This case study suggests that a campaign approach can be used to provide high-volume quality VMMC services without compromising client safety, and provides a model for matching supply and demand for VMMC services in other settings.
- Voluntary Medical Male Circumcision: Strategies for Meeti... by Kelly Curran, Emmanuel Njeuhmeli, Andrew Mirelman, Kim Dickson, Tigistu Adamu, Peter Cherutich, Hally Mahler, Bennett Fimbo, Thembisile Khumalo Mavuso, Jennifer Albertini, Laura Fitzgerald, Naomi Bock, Jason Reed, Delivette Castor, David Stanton Voluntary medical male circumcision (VMMC) reduces female-to-male HIV transmission by approximately 60%; modeling suggests that scaling up VMMC to 80% of men 15- to 49-years-old within five years would avert over 3.3 million new HIV infections in 14 high priority countries/regions in southern and eastern Africa by 2025 and would require 20.33 million circumcisions. However, the shortage of health professionals in these countries must be addressed to reach these proposed coverage levels. To identify human resource approaches that are being used to improve VMMC volume and efficiency, we looked at previous literature and conducted a program review. We identified surgical efficiencies, non-surgical efficiencies, task shifting, task sharing, temporary redeployment of public sector staff during VMMC campaign periods, expansion of the health workforce through recruitment of unemployed, recently retired, newly graduating, or on-leave health care workers, and the use of volunteer medical staff from other countries as approaches that address human resource constraints. Case studies from Kenya, Tanzania, and Swaziland illustrate several innovative responses to human resource challenges. Although the shortage of skilled personnel remains a major challenge to the rapid scale-up of VMMC in the 14 African priority countries/regions, health programs throughout the region may be able to replicate or adapt these approaches to scale up VMMC for public health impact.
- Effect of Supplementation with Zinc and Other Micronutrie... by Jacobien Veenemans, Paul Milligan, Andrew M. Prentice, Laura R. A. Schouten, Nienke Inja, Aafke C. van der Heijden, Linsey C. C. de Boer, Esther J. S. Jansen, Anna E. Koopmans, Wendy T. M. Enthoven, Rob J. Kraaijenhagen, Ayse Y. Demir, Donald R. A. Uges, Erasto V. Mbugi, Huub F. J. Savelkoul, Hans Verhoef Background It is uncertain to what extent oral supplementation with zinc can reduce episodes of malaria in endemic areas. Protection may depend on other nutrients. We measured the effect of supplementation with zinc and other nutrients on malaria rates. Methods and Findings In a 2×2 factorial trial, 612 rural Tanzanian children aged 6–60 months in an area with intense malaria transmission and with height-for-age z-score≤−1.5 SD were randomized to receive daily oral supplementation with either zinc alone (10 mg), multi-nutrients without zinc, multi-nutrients with zinc, or placebo. Intervention group was indicated by colour code, but neither participants, researchers, nor field staff knew who received what intervention. Those with Plasmodium infection at baseline were treated with artemether-lumefantrine. The primary outcome, an episode of malaria, was assessed among children reported sick at a primary care clinic, and pre-defined as current Plasmodium infection with an inflammatory response, shown by axillary temperature ≥37.5°C or whole blood C-reactive protein concentration ≥8 mg/L. Nutritional indicators were assessed at baseline and at 251 days (median; 95% reference range: 191–296 days). In the primary intention-to-treat analysis, we adjusted for pre-specified baseline factors, using Cox regression models that accounted for multiple episodes per child. 592 children completed the study. The primary analysis included 1,572 malaria episodes during 526 child-years of observation (median follow-up: 331 days). Malaria incidence in groups receiving zinc, multi-nutrients without zinc, multi-nutrients with zinc and placebo was 2.89/child-year, 2.95/child-year, 3.26/child-year, and 2.87/child-year, respectively. There was no evidence that multi-nutrients influenced the effect of zinc (or vice versa). Neither zinc nor multi-nutrients influenced malaria rates (marginal analysis; adjusted HR, 95% CI: 1.04, 0.93–1.18 and 1.10, 0.97–1.24 respectively). The prevalence of zinc deficiency (plasma zinc concentration Conclusions We found no evidence from this trial that zinc supplementation protected against malaria. Trial Registration ClinicalTrials.gov NCT00623857 Please see later in the article for the Editors' Summary.
Forbes.com: Health News
- Lipitor is Dead. Long Live Lipitor! There are a number of pieces out today about the advent of generic versions of Lipitor, the LDL-cholesterol-lowering drug that has been the world's best-selling medicine of all time. I'd like to highlight two pieces out today on the subject, but before that, I want to express thanks to Sen. Orrin Hatch (R., Utah) and Rep. Henry Waxman (D., Calif.) for helping to design the world's most innovative and efficient pharmaceutical market.
- The Case For Investing In Health IT Start-Ups I read Fred Wilson's recent musings on health care. The -based venture capitalist recently turned down the opportunity to invest in the start-up of an unnamed health care entrepreneur, who actually made money when he sold his first company. Wilson wrote: "When we look at healthcare, what's wrong with it, and what needs to happen ...
- Why Conrad Murray, a Convicted Felon, Remains on the Medi... Yesterday in Los Angeles, Dr. Conrad Murray was sentenced to four years in prison for helping to kill Michael Jackson by prescribing him propofol, an industrial-strength anesthetic, for Jackson's insomnia. California Superior Court Judge Michael Pastor called Murray a "disgrace to the medical profession" who had committed a "horrific violation of trust." Dr. Murray was convicted on November 7, and the State of California suspended his medical license back in January. But not to worry: Murray can continue to get paid by Medicare.
- A Graphic Use Of Drugs: How One Patient Visualized His He... Starting in childhood, Ken Spriggs grappled with eczema, then asthma. In 2001, he was diagnosed with Crohn's, a debilitating disease which causes inflammation of the digestive tract. He dealt with scores of doctors, some good,??some incompetent. So, when he heard Dave deBronkart, aka e-Patient Dave, at a TED talk in April, it??spurred him to take ...
- Don Berwick, Martyr for Socialized Medicine It is, assuredly, comforting for Obamacare's advocates to declare that Berwick was done in by partisan Republican squabbling. But the fact is that it was the White House that decided not to let Berwick go up to the Senate for a confirmation hearing, a hearing that Republicans were looking forward to. This was a blatant attempt by the President to avoid a proper, public debate between Berwick's philosophy and that of his Senatorial critics. Perhaps Berwick would have won that debate in the eyes of the public. Thanks to the President, we'll never know.
- Why the American Medical Association Had 72 Million Reaso... As Paul Starr chronicled in his Pulitzer Prize-winning book, The Social Transformation of American Medicine, the American Medical Association played a key role in establishing the power of doctors in the American health-care system, and thereby in the outsized compensation that American physicians enjoy relative to their developed-world counterparts. In the 21st Century, however, the AMA has been actively responsible for lowering doctors' pay, in moves that enriched the AMA's Washington headquarters at the expense of its members. Here's what happened.
- Wait. What? Democrats for Premium Support-Based Medicare ... I had to rub my eyes a few times to make sure I wasn't hallucinating when I came across this sentence from Robert Pear of the New York Times: "Members of both parties told the [Congressional Supercommittee] that Medicare should offer a fixed amount of money to each beneficiary to buy coverage from competing private plans, whose costs and benefits would be tightly regulated by the government." It's not clear how many Democrats Pear has spoken to, but his article raises the hope that premium support, the best proposed approach to Medicare reform, could make it through the next Congress under a new President.
- Forget Preventive Health Care: Let Them Eat Vegetables I have the good fortune of teaching students at Vanderbilt's Owen Graduate School of Management. Holding forth on my favorite topic recently - health care - I once again found myself overturning many misconceptions. One of the deeply held beliefs among the current generation is that preventive services are good, cost-effective, and should be consumed ...
- The Myth of Americans' Poor Life Expectancy It's one of the most oft-repeated justifications for socialized medicine: Americans spend more money than other developed countries on health care, but don't live as long. If we would just hop on the European health-care bandwagon, we'd live longer and healthier lives. The only problem is it's not true.
- FTC Commissioner: Accountable Care Organizations Will Lik... In August, I wrote about how hospital monopolies are the biggest driver of health costs that nobody talks about. These powerful hospital chains know that insurers have no choice but to accept their jacked-up rates, and the cost of health insurance goes up at their whim. Now, according to remarks by Federal Trade Commissioner J. Thomas Rosch, it turns out that accountable care organizations???one of Obamacare's most touted policy gizmos???could make this problem far worse. "The net result" of ACOs, says Rosch, "may therefore be higher costs and lower quality health care???precisely the opposite of its goal."
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
- Hirsutism or Excess Hair From NHS Choices YouTube channel: Hirsutism causes excess hair growth in women, such as on the face and chest. An expert explains the causes or hirsutism, treatments such as hair-removal and cosmetic techniques, and where to go for help if you're worried about excess hair growth.The Cleveland Clinic Journal of Medicine published an Update on the management of hirsutism in 2010:Hirsutism is a source of significant anxiety in women. While polycystic ovary syndrome (PCOS) or other endocrine conditions are responsible for excess androgen in many patients, other patients have normal menses and normal androgen levels (“idiopathic” hirsutism).The finding of polycystic ovaries on ultrasound is not required for the diagnosis of polycystic ovary syndrome (PCOS). Gonadotropin-dependent ovarian hyperandrogenism is believed to cause PCOS. However, mild adrenocorticotropic-dependent adrenal hyperandrogenism also is a feature in many cases.Even women with mild hirsutism can have elevated androgen levels, and thus, they may benefit from a laboratory evaluation.Laser treatment does not result in complete, permanent hair reduction, but it is more effective than other methods such as shaving, waxing, and electrolysis. It produces hair reduction for up to 6 months. The effect is enhanced with multiple treatments. Interestingly, a portable laser hair removal device is currently available from Amazon (this post is not a recommendation or endorsement of the product).References:Update on the management of hirsutism. Cleveland Clinic Journal of Medicine June 2010 vol. 77 6 388-398.A home hair removal laser device is available without prescription from Amazon.com (not a recommendation to buy any product, see the link below). A similar device is available from Costco. Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
- Cleveland Clinic calls "Code Lavender" to improve patient... From the WSJ:How patients feel they were treated has always colored their opinions of a hospital. Now, those feelings are being factored into how hospitals get paid.The Cleveland Clinic CEO, Dr. Cosgrove, says that in his own days as a top cardiac surgeon, he focused so intently on reducing complications from cardiac procedures that he gave little thought to the feelings or experiences of patients.Times have changed dramatically since then. The Cleveland Clinic has launched a program known as HEART - for hear the concern, empathize, apologize, respond and thank—that empowers employees to handle patient concerns from the moment they arise. It developed a Healing Services team to offer complimentary light massages, Reiki—a laying on of hands—aromatherapy, spiritual care from a clergy person or lay practitioner and other holistic services, and it will call a "Code Lavender" for patients or family members under stress who need immediate comfort.Since 2008, the Cleveland Clinic's overall hospital ratings have increased by 89%."Code Lavender" has a Twitter account too (@CodeLavender), managed by the former Cleveland Clinic Chief Experience Officer who popularized the term.From the Cleveland Clinic Twitter account: Efforts to improve patient satisfaction were featured in a NBC Nightly News story (see the video below).References:A Financial Incentive for Better Bedside Manner. WSJ.Image source: Lavender Farm, Wikipedia, public domain.Disclaimer: I was an Assistant Professor of Medicine at Cleveland Clinic from 2005 to 2008.Comments from Twitter:@TanyaPRpro (Tanya R. Walton): Clever and meaningful hospital care@scottRcrawford: Brand medicine@gruntdoc: How sad. Condolences. RT @DrVes: Cleveland Clinic calls "Code Lavender" to improve patient satisfaction goo.gl/X4Jtt@MGastorf (Melissa Gastorf): concerns about satisfaction basis for payment- i.e. if you refuse to write narcotic and patient angry, physician payment suffers. Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
- Acute altitude illnesses This summary is based on a recent BMJ review:Acute altitude illnesses include:- high altitude headache- acute mountain sickness- high altitude cerebral edema- high altitude pulmonary edemaTypical scenarios in which such illness occurs include:- a family trek to Everest base camp in Nepal (5,360 m)- a fund raising climb of Mount Kilimanjaro (5,895 m), shown in the map below- a tourist visit to Machu Picchu (2,430 m)View Larger MapHigh altitude headache and acute mountain sickness often occur a few hours after arrival at altitudes over 3,000 meters.Occurrence of acute mountain sickness is reduced by slow ascent. Severity can be modified by prophylactic acetazolamide.Mild to moderate acute mountain sickness usually resolves with:- rest- hydration- halting ascent- analgesicsOccasionally people with acute mountain sickness develop high altitude cerebral oedema with confusion, ataxia, persistent headache, and vomiting.Severe acute mountain sickness and high altitude cerebral edema require urgent treatment with:- oxygen if available- dexamethasone- possibly acetazolamide- rapid descentHigh altitude pulmonary edema is a rare but potentially life threatening condition that occurs 1-4 days after arrival at altitudes above 2,500 meters. Treatment includes oxygen if available, nifedipine, and rapid descent to lower altitude.References:Clinical Review: Acute altitude illnesses. BMJ 2011; 343:d4943 doi: 10.1136/bmj.d4943 Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
- Linaclotide for treatment of constipation - minimally abs... Linaclotide is a minimally absorbed peptide agonist of the guanylate cyclase C receptor. It consists of 14 amino acids. The sequence is:H–Cys1–Cys2–Glu3–Tyr4–Cys5–Cys6–Asn7–Pro8–Ala9–Cys10–Thr11–Gly12–Cys13–Tyr14–OHTwo randomized, 12-week trials included 1,300 patients with chronic constipation (NEJM, 2011). Patients received either placebo or linaclotide once daily for 12 weeks.The incidence of adverse events was similar among all study groups, with the exception of diarrhea, which led to discontinuation of treatment in 4.2% of patients in linaclotide groups.Linaclotide reduced bowel and abdominal symptoms in patients with chronic constipation. Additional studies are needed to evaluate the potential long-term risks of linaclotide in chronic constipation.References:Two Randomized Trials of Linaclotide for Chronic Constipation. N Engl J Med 2011; 365:527-536August 11, 2011.Image source: Colon (anatomy), Wikipedia, public domain. Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
- Holiday time can be really stressful for patients with ea... From Mayo Clinic YouTube channel:For people with eating disorders such as binge eating disorder, bulimia nervosa and anorexia nervosa, the holiday season can be a nightmare.People with eating disorders usually begin to worry about food consumption at holiday gatherings weeks sometimes even months - before the event, says Leslie Sim, Ph.D., clinical director of the Mayo Clinic Eating Disorders Program. "It's really a stressful time because there are large amounts of food around."Dr. Sim suggests a few tips to navigate through holiday gatherings:- Have a plan. People with eating disorders should eat like they would on a normal day and not skip any meals. Make sure to eat breakfast, lunch, and a light snack in addition to the meal. People who starve themselves are more likely to skip out on the meal entirely or engage in binge eating.- If family or friends know someone is struggling with an eating disorder, it's not a good idea to comment on their weight during a holiday gathering. Even a compliment can be taken the wrong way.- If you're hosting a holiday gathering with plenty of food, don't take offense if someone doesn't eat.- People with eating disorders should have a coping strategy if they begin to feel stressed during a gathering. Such tactics include deep breathing, meditation and talking to a close friend of family member. Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
- A blog can help your career - and even if it doesn't, it'... From CNN:There is strong evidence that people who use their blog as a career tool do better. In 2005, a Pew survey found that people who blog are generally higher earners. People who use social media end up finding jobs that are a better fit.Changing your career and skipping entry-level positions can be easier if you have a blog.Most importantly, a blog is a great platform for networking. Just look at this picture from the annual CME meeting Essentials of EM 2011.A blog is a good way to meet other people who think like you do and who are in your field. It helps you to make real connections with them based on ideas and passions. Social media use allows you to focus your connections on other top performers, since blogging about career topics probably self-selects for engaged and motivated people.Social media in medicine: How to be a Twitter superstar and help your patients and your practiceThe key concept is TIC, Two Interlocking Cycles:- Cycle of Patient Education- Cycle of Online Information and Physician EducationThe two cycles work together as two interlocking cogwheels (TIC).Cycle of Patient Education (click here to enlarge the image). An editable copy for your presentation is available at Google Docs.Cycle of Online Information and Physician Education (click here to enlarge the image). An editable copy for your presentation is available at Google Docs. Feel free to use the images in your own presentations with credit to AllergyCases.org.References:Blog your way to a better career. CNN.Social media in medicine: How to be a Twitter superstar and help your patients and your practice Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
- Tinnitus is perception of sound where there is none Just a few days ago, British newspapers reported that a rock fan committed suicide to relieve tinnitus that he had for 3 months after a supergroup's gig. Tinnitus is characterized as perception of sound where there is none. Read more about tinnitus in this blog post. The Cleveland Clinic Journal of Medicine recently published a review on Tinnitus: Patients do not have to ‘just live with it’ and Tinnitus relief: Suggestions for patients.From NHS Choices YouTube channel: Tinnitus causes people to hear constant sounds in one ear, both ears or in their head. An audiologist explains the possible causes and effects it often has, such as stress and anxiety, plus how to deal with them. Ashleigh, who was diagnosed with tinnitus in 2005, describes how she copes with it.Lars Ulrich, the drummer for the heavy metal band Metallica, also struggles with tinnitus and warns his fans that "once your hearing is gone, it's gone. I've been playing loud rock music for the better part of 35 years," said Ulrich, 46. "I never used to play with any kind of protection."Early in his career, without protection for his ears, the loud noise began to follow Ulrich off-stage. "It's this constant ringing in the ears," Ulrich said. "It never sort of goes away. It never just stops." This is a classic description of tinnitus, a perception of sound where there is none (phantom ear sounds).The military is generating a tremendous number of tinnitus patients, according to a recent CNN report on the problem.Tinnitus differential diagnosis: Q SALAMI mnemonicQuinidineSalicylates (aspirin)Aminoglycoside antibiotics (ABx)LabyrinthitisAcoustic neuroma, CN VIIIMeniere’s diseaseIncreased blood pressure (BP) (HTN)References:Metallica drummer struggles with tinnitus: "Once your hearing is gone, it's gone"Metallica drummer struggles with ringing in ears. CNN.Tinnitus: Patients do not have to ‘just live with it’. CCJM, 2011.Tinnitus relief: Suggestions for patients. CCJM, 2011.Rock Fan Commits Suicide to Relieve Tinnitus From Supergroup's Gig: Daily Mail and Fox News. Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
- "Family practitioners in the US are facing extinction. In... From the Lancet review of the University of Pennsylvania nursing school:Family practitioners in the US are facing extinction. In their place must come nurse-practitioners. Nurses are better educated to navigate and refer patients to specialists. They don't have any illusions about managing complex illness. Their lower threshold for referral means less risk of missing diagnoses or delaying expert care.This is one vision for nursing to be found at the University of Pennsylvania's extraordinary School of Nursing. I'm not sure if this is the best model for primary care in the U.S. What do you think?References:Offline: Nursing, but not as you know it. The Lancet, Volume 378, Issue 9805, Page 1768, 19 November 2011.Image source: OpenClipArt.org, public domain.Comments from Twitter:@scanman: Looks like doctors will be an endangered genus in the US within this century@MGastorf: so disagree. I know that is being pushed but I can provide far more complete care than nurse practitioner.@davisliumd: Umm, No -> RT @DrVes Family practitioners in the US are facing extinction. In their place must come nurse-practitioners@davisliumd: Agree -> RT @drves: @davisliumd that was actually a quote from The Lancet, not my opinion: j.mp/w33Kvq. Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
- Where citations come from Source: http://xkcd.com/978 Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
- A doctor admits: "I love to blog but I still don’t real... From Mike Cadogan, the founder of one the most popular medical blogs Life in The Fast Lane, based in Australia:I blog to vent, to educate, to converse, to cogitate, to archive thoughts and to stimulate discussion.I love the concept of a launching a thought, an image, a moment… into the inferno of the blogosphere, and observing the response.With the average blog-reader attention span being around 90 seconds, I find that most of my ‘good’ posts – thoroughly researched, with well constructed arguments and propositions… are lost on this ‘average‘ reader… Yet, strangely I feel better having taken the time to arrange my thoughts, review the evidence and archive the information.The advent of Facebook and Twitter has changed the way readers comment and share, and in many cases the promoted discussion continues out-with the confines of the original medium…I love to blog but I still don’t really know why…My reply is here:You blog because you have to, Mike. And we are lucky to have you as a writer.I have more prosaic and simple reasons to keep several blogs focused on different aspects of clinical practice: internal medicine, allergy and immunology, pediatrics, and IT.I simply blog as a way to keep track of the new developments in medicine that are relevant to my practice and patients. The blog is a digital notebook and an archive accessible from any place and device with an internet connection.A lot of people find it useful and that's great but this is an added bonus. If I don't find a blog post interesting and useful, I don't hit the "publish" button. A custom-made Google search engine makes it all searchable in 0.2 seconds. It just works.Quotes from an interview with Seth Godin and Tom Peters:"Blogging is free. It doesn’t matter if anyone reads it. What matters is the humility that comes from writing it. What matters is the metacognition of thinking about what you’re going to say.No single thing in the last 15 years professionally has been more important to my life than blogging. It has changed my life, it has changed my perspective, it has changed my intellectual outlook, it’s changed my emotional outlook.And it’s free."Comments from Google Plus:Neil Mehta - Loved your poetic post. I attempted to reflect on this earlier this year and came up with some reasons http://blogedutech.blogspot.com/2011/05/reflections-on-why-do-i-blog.html but find that it does not come close to your beautiful prose. Thanks for sharing.References:Why I Blog?Why I Blog: Andrew Sullivan from The Atlantic Shares His Thoughts on BloggingWhy Do I Blog?Why blog? Notes from Dr. RW. A perfectly reasonable list. All doctors should consider blogging. It's do-it-yourself CME. Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.
Medgadget
- Mindray DC-T6 Ultrasound Introduced at RSNA Mindray is unveiling a new budget conscious general purpose ultrasound at the RSNA this week. Although designed for vascular applications, the system can be used in a variety of clinical scenarios.The DC-T6 features a 15 inch adjustable TFT screen, up to two hours of scanning per battery charge, and common features like 4D and tissue doppler imaging, as well proprietary speckle reduction and image resolution management.Read More
- SJM Quadripolar Pacing System Gets FDA Clearance Having received European approval in September, St. Jude Medical now announced FDA clearance of its Unify Quadra cardiac resynchronization therapy defibrillator (CRT-D) and the matching Quartet Left Ventricular Quadripolar Pacing Lead. The lead features four electrodes and the CRT-D is able to take advantage of them by providing up to ten different pacing configurations.Because the electrodes cover a greater area, precise placement of the lead is less critical as adjustments of the electrical signal can be made via software. Like many other implantable devices from St. Jude, the Unify Quadra can wirelessly interface with the Merlin.net system for reporting both on the health of the patient and the status of the device.Read More
- Centricity Mobile Access Radiology App from GE Approved ... GE Healthcare has just announced diagnostic clearance by the FDA for company’s Centricity Radiology Mobile Access 2.0 application for iOS devices.The technology allows clinicians to remotely access images and reports from GE’s Centricity picture archiving and communications platform (PACS), without downloading any personal data to the portable client device.Read More
- iPad App, a Live Drama Theater for Cath Procedures A cardiac catheterization lab in Israel is now offering the ultimate in reality TV by letting relatives watch the procedure live using an iPad while back in the waiting room. Developed with the Mckesson Company the app streams fluoroscopy shots and other pertinent info collected during the procedure, and also provides post-op review for the clinician and an easy and intuitive look for the patient to see what has been done.More from the Jerusalem Post…Read More
- Vizua 2D/3D Imagery Gone Mobile At RSNA 2011 in Chicago this week we took an opportunity to see a demo Vizua’s system for radiological image sharing. The cloud-based system allows anyone practically with any modern computer or mobile device to see and navigate through rendered data sets from a variety of modalities. Rendering is done on the server and the images are streamed directly to the device, allowing for beautiful, high res images without needing a powerful processor.Read More
- Siemens Introduces Next-Generation PET-CT System, Biograp... Siemens Healthcare introduced its next-generation Biograph mCT, a positron emission tomography-computed tomography (PET-CT) scanner at the annual meeting of the Radiological Society of North America (RSNA) in Chicago. The new Biograph mCT incorporates the Siemens OptisoHD (High-Definition) Detector System, which will feature a volumetric resolution of 87 mm3. Other technologies include Time of Flight and High-Definition PET, ensuring fast, precise images with minimum radiation dose. This enables precise measurements of metabolic processes including the assessment of neurological disease, cancerous tissue and cardiac blood flow.In this device the diagnosis of neurodegenerative diseases, such as dementia, got a special focus. With potential new PET biomarkers, reliable imaging of beta-amyloid plaque in the brain may be possible, providing information to aid in the diagnosis of dementia, potentially slowing disease progression through earlier care.Read More
- Sophisticated 3-D Computer Model to Improve Human Face Tr... In an effort to improve the techniques used for human face transplantation, researchers from the University of Pittsburgh Medical Center (UPMC) have combined 3-D modelling techniques from the film industry with conventional medical imaging.The new technique makes use of the information of multiple imaging exams and creates a sophisticated 3D computer reconstructions. The computer modelling software can integrate information from several imaging modalities, like 3D CT, CT angiography, MRI and high-definition tractography to create the 3D model of the anatomy of the head and neck. This same technology is being used in movies to animate computer-generated characters.Read More
- Completing the Circuit to Curb Obesity Obesity is the most significant chronic healthcare crisis facing the United States, as well as other countries. Already 1 out of every 3 adults, and 1 out of every 6 children or adolescents, in the U.S. is obese! Leptin is a hormone that has received considerable attention since its discovery in 1994 for its role in regulating metabolism (like a thermostat, or adipostat) and implications for obesity. High leptin levels are associated with feeling satiated and an active metabolism. Though many overweight people have high levels of circulating leptin, it’s been found that their hypothalamic neurons do not receive the signal – a phenomenon known as “leptin resistance.” An animal model that mirrors this is db/db mice, which lack leptin receptors on the surface of they hypothalamic neurons and are therefore morbidly obese (see image).Reporting in Science this past week, researchers at Harvard Medical School transplanted neurons with the leptin receptor into the hypothalami of db/db mice and as a result were able to partially restore leptin sensitivity and ameliorate their obesity. Two to three months after transplanting 15,000 (a relatively small number) fluorescently-tagged, leptin sensitive neurons into the db/db mice hypothalami, they observed statistically significant drops in blood sugar levels, leptin concentration, and fat mass. In terms of the mechanism and implications, the team concludes:Read More
- World’s First Artificial Trachea Transplant Patient Get... A few months ago we reported about the first artificial trachea transplant performed at Karolinska Institutet in Sweden. A patient had a carinal tumor that extended to the lowest 5 cm of the trachea along with the bronchi, so removal alone couldn’t save the patient. The team of surgeons removed the affected area and replaced it with a synthetic engineered trachea. The project was headed by Professor Paolo Macchiarini. Now, five months later, the study and successful outcome has been published in The Lancet by the doctors who performed the procedure.The successful outcome of this operation, involving a transplant made of stem-cell-seeded nanocomposite, provides proof of the viability of this approach. Macchiarini says this method offers advantages, like preventing rejection or use of immunosuppressive drugs by using the patient’s own cells. Also, the implant can be tailor-made for the patient, because it is artificially constructed.Read More
- Philips Unveils Veradius Neo, a Mobile C-arm System with ... Royal Philips Electronics introduced the Veradius Neo, a counter-balanced mobile C-arm with a thin flat detector. It is the second generation of flat detector mobile C-arms based on the Veradius line introduced in 2009. The system consists of a C-arm stand with a compact foot and rear-wheel steering for easy maneuverability and positioning.The flat detector and special geometry allows clinicians to easily and precisely handle patients and perform procedures with difficult positioning challenges. Designed in collaboration with surgeons from around the world, Veradius Neo features a completely new geometry to also accommodate obese patients that are difficult to maneuver around.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
- Impersonal care from the new generation of physicians Historically, American physicians and surgeons were fiercely independent practitioners, who owned their own practices, worked long days and maybe longer nights, made a good income, but saw little of their families. They trained in a male-dominated world in “residency,” so named originally because their extended 120 hour/week work schedule demanded them living in dormitory type [...]
- I eat lunch with drug company representatives and I’m p... Today, I want to review another article I wrote in last year. That article started with a confession: ”I confessed that I ate lunch with a representative of a pharmaceutical company.” I must now confess that I often eat lunch with representatives of pharmaceutical companies and I’m proud of it. At this stage of my career, [...]
- Top stories in health and medicine this morning, December... This series is brought to you by MedPage Today. 1. Generic Lipitor: New Era for Statins? After a long and successful run as a branded statin, Lipitor (atorvastatin) will be available as a generic. 2. Baby’s Flat Head Rarely Requires Helmet, Surgery. The push to put babies to sleep on their back to reduce the [...]
- Cancer rehab dramatically improves cancer care In this day and age, with excellent rehabilitation care available for nearly every injury or illness—no matter how serious—it’s hard to believe that there are millions of people who leave the acute medical system far worse off than they entered it, and aren’t routinely offered rehab. I’m talking about cancer survivors– a group of individuals [...]
- The art of Alzheimer’s disease Physicians are not trained to interpret paintings, and most patients do not have a lifetime of artwork to analyze. However, a rare opportunity for both to occur is at the Museum of Modern Art’s exhibition de Kooning: A Retrospective. Wilem de Kooning, regarded as one of the most prolific American artists of the twentieth century, [...]
- The therapeutic value of touch in medicine My wife has two world-class oncologists who help her manage her stage 4 lung cancer. Both are excellent clinicians. Yet their skills differ in one very important way. Her radiation oncologist physically touches her a lot (in a good way of course!). There are the touches on her arm, a hand on the shoulder, hugs, [...]
- When applications ask about your psychiatric history Sam is young man is applying for a summer program, a real resume builder. Among other things, the application asks if he has been treated for a psychiatric disorder. In fact, he’s seen a therapist and he’s felt anxious at times. His internist gave him some Lexapro samples and he feels better. The symptoms of [...]
- Top stories in health and medicine this morning, November... This series is brought to you by MedPage Today. 1. 30-Day Readmissions High After PCI. Nearly 10% of patients undergoing angioplasty and other percutaneous interventions (PCI) at the Mayo Clinic were readmitted within 30 days after discharge, but the extent to which the readmissions reflected faulty initial treatment was unclear. 2. Anti-Smoking Programs Pay Off. [...]
- Is it a crime that retainer physicians make more money? Many readers know that I co-authored an Annals of Internal Medicine article on retainer medicine. The article has received (as expected) mixed reviews, because the concept causes angst for some physicians. I believe (and I will not speak in this rant for my co-author) that retainer medicine emerged because of the current payment system. Retainer [...]
- Health IT has problems, but is worth the price I started working with computers in medicine in 1963. I was a Captain in the United States Army Medical Corps in San Francisco when a Lieutenant Colonel told me to “automate the California Tumor Tissue Registry.” I said, “Yes, Sir. How would I do that?” He told me to walk across the Presidio parking lot [...]
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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- Discussion posted by Srikanth Garlapati Discussion posted by Srikanth GarlapatiA 13 year old boyChief complaint:Fever and multiple skin lesions 2 days prior to admissionPresent illness:10 days prior to admission,the patient was admitted at a private hospital because of high continuous fever. He had no nausea, emesis or any URI symptoms at that time. The final diagnosis was Dengue hemorrhagic fever. He was treated by 4000cc intravenous fluid and was discharged after four days. The platelet count had normalized before the discharge.5 days prior to admission,He has low grade fever every afternoon. The parents gave him antipyretics for the symptoms3 days prior to admission,the patient complained of pain in his left index finger and right second toe. He was still able to walk and perform his daily activities. His parents took him to a private clinic, where he was given some analgesics and antibiotics. The fever somehow subsided in these few days.2 days prior to admission,multiple skin lesions appeared on his body. They were vesicles, bullae and varying size of purpuric spots which occurred simultaneously.1 day prior to admission,the lesions expanded rapidly and progressed over the patient’s face and extremities. They also became painful. The patient felt excruciating pain in multiple joints, including both elbows, both knees and the previously affected digits. He was lethargic so his parents decided to take him to the hospital.Past history:He is the only child. He was born by Cesarean section at a private hospital. He was fully vaccinated and has no history of any serious medical illness. He took no medication before this illness. He has not been out of the community in the past few months. His residence is in the country where there are paddy fields and orchards. He used to catch fish in the fields 3 months agoPhysical examinations:Vital signs: Temperature 39.6 oC Blood pressure 90/50 mmHg, Respiratory rate 32 breaths/min Pulse rate 130 beats/minGeneral appearance: A boy, febrile, good consciousnessHEENT: not pale, no icteric sclera, no injected pharynx, tonsils: not enlarged, normal tympanic membranesLymph nodes: right cervical lymph nodes 1.5 cm in diameterHeart: regular rhythm, normal S1, S2, no murmurLungs: equal breath sounds, bilateral crepitation, no wheezingAbdomen: soft, no point of tenderness, no abnormal mass. Liver, spleen: not palpableExtremities: marked tender at both knee and elbow joints. Gangrene at left index finger and right second toe Skin: generalized, multiple hemorrhagic and pustular blebs and purpura scattered over face, body, extremities, palms and soles, spared mucous membrane. Laboratory investigationsCBC: Hb 11.5g% Hct 35% WBC 13,500/mm3 (N93%, L7%), platelet count: 216,000/mm3BUN 56 mg% Cr 1.9mg% Na 126 K 4.7 Cl 94 CO2 18 mEq/LPT 14.6 (control 11.5min) PTT 32.7(control 32.3min) INR 1.28LP: pressure 10 cmH2O, WBC 10 /mm3, all mononuclear cells, 100RBC/mm3 no organisms on Gram stain, Protein 38 mg%, sugar 82mg% in blood sugar 166mg%LFT: TP 6.1g% Alb 2.8g% Glob 3.3g% Chol l54g% AlkP 189u/L SGOT 135U/L SGPT 104U/L TB 2.67mg% DB 2.16mg%CXR : as shownFluid&Pus from blebs: Many Gram negative bacilli, many PMNCourse in the hospitalAfter admission the patient developed shock and did not responded to supportive and antibiotic (cotrimoxazole , amikacin and cetazidime) therapy. He died 22 hours after admission.What are the DD'sSee More
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