Category Archives: General Health

Great Story -How CAR-T Came About

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While chimeric antigen receptor T-cell (CAR-T) therapy does not have much to do with pediatric gastroenterology, the development of this therapy, described recently (L Rosenbaum NEJM 2017; 377: 1313-5), holds lessons about perseverance and chance that are widely applicable.

CAR-T involves genetically engineering the patient’s own T cells to kill tumor cells. It recently received FDA approval to treat patients up to 25 years of age with relapsed or refractory acute lymphoblastic leukemia.

The story of the survival of Emily Whitehead, the index patient for this therapy, is suitable for Hollywood.  The groundwork for this very expensive treatment dates back to 1893 with William Coley’s recognition of the immune system’s potential for treating cancer –he injected streptococcus into an inoperable osteosarcoma and observed tumor shrinkage.

Key Steps in this Story:

  1. University of Pennsylvania’s immunologist Carl June spent his career working on CAR-T. His wife died of ovarian cancer in 2001 and he resolved to develop this emerging immunotherapy that he had wanted for her.
  2. Barbara and Edward Netter provided key funding for this project in 2008.  They too had lost a close family member to cancer.
  3. Emily Whitehead nearly died due to CAR-T therapy which triggered cytokine-release syndrome, which was not a recognized entity at the time.  In part due to chance, extremely high levels (>1000-fold) of interleukin-6 (IL-6) were detected quickly due to the ability of the institution and prodding by the researchers to their colleagues.  This allowed the experimental use of tocilizumab, a monoclonal antibody that targets IL-6.
  4. Her survival helped reenergize this line of research.

My take (borrowed from author): “Therapeutic advances are motivated by more than money –that it’s the hope, vision, and perseverance of both patients and investigators that made this …possible.”

Acute esophageal necrosis ina a 63 year-old that resolved with conservative treatment.  “The cause is unknown..[it] occurs most commonly in the distal third of the esophagus, which is hypovascular” often in the setting of chronic disease.

We Are Last in Health Care Among High-Income Countries

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In a recent commentary (EC Schneider, D Squires. NEJM 2017; 377: 901—4) explains why the U.S. Health Care System is last among high-income countries.

Overall, the U.S. “begins with a challenge: its population is sicker and has higher mortality than those of other high-income countries.”  The U.S. has a rate of death from “conditions that can be managed and treated effectively (referred to as ‘mortality amenable to health care’) is far higher than in other high-income countries.

Four areas that have to be addressed to help U.S. move from last to first:

  • U.S. must confront lack of access to health care. The top-ranked countries offer universal insurance coverage with minimal out-of-pocket costs for preventive and primary care.
  • Underinvestment in primary care. In other countries, a higher percentage of “the professional workforce is dedicated to primary care than to specialty care.”
  • Administrative inefficiency. “Both patients and professionals In the United States are baffled by the complexity of obtaining care and paying for it.”
  • Disparities in the delivery of care. This may be mediated in part by a less robust social safety net than other high-income countries.  “Social spending [for] stable housing, educational opportunities, nutrition, and transportation may reduce the demand for” many health care services.

My take: It makes me mad that our health care system performs so poorly compared to other countries.

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Firearm Mortality -Tragic Inertia

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When it comes to gun violence, the U.S. is the leader among developed nations.  It is sad how that despite the magnitude of this problem there are not significant efforts to mitigate this tragedy.

We know from Australia’s experience that changes in gun laws can make a big difference: Link: Gun Law Reforms and Firearm Mortality, Australia 1979-2013

Politico report: The gun lobby: See how much your representative gets

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What a 5-Star Online Evaluation Means

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Bloomberg news: Don’t Yelp Your Doctor. Study Finds Ratings Are All Wrong.

Here’s an excerpt:

If you’re looking for the best doctor, online ratings are unlikely to be much help.

That’s the determination of researchers at Cedars-Sinai Medical Center in Los Angeles, who compared reviews of 78 of the medical center’s specialists on five popular ratings sites with a set of internal quality measures and found there was essentially no correlation…

Brennan Spiegel, a gastroenterologist and co-author of the study, said that may be the right way to think about reviews — as gauges of things the patient can observe.

“It may be that these ratings are a good measure of the front-office service or the interpersonal style of the physician,” said Spiegel, a professor and director of health services research at Cedars-Sinai. “We’re not saying that there’s no value to these online ratings — we’re saying don’t confuse those ratings in any way, shape or form with the actual technical skill.”

The study, published online on Friday in the Journal of the American Medical Informatics Association, compared measures developed by Cedars-Sinai with users’ ratings on five sites: Healthgrades, Yelp, Vitals, RateMDs and UCompareHealthCare. The internal performance metrics include reviews from doctors’ colleagues and administrators, how often patients are readmitted and how long they remain in the hospital, and adherence to practice guidelines.

My take: I’ve been told that the key to patient care are the 3 A’s: availability, affability, and ability.  Online evaluations likely can help assess the first two A’s; in addition, these sites allow for constructive criticisms but they need to evolve to include other measures of physician performance.  Nevertheless, ignoring online evaluations (eg. digital reputation)  would be a mistake for physicians –they are here to stay.

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Physician Burnout Spreading (Part 2)

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A recent article (JC Anderson et al. Am J Gastroenterol 2017; 112:1356–1359; doi: 10.1038/ajg.2017.251; published online 8 August 2017) also addresses the topic of physician burnout with a focus on gastroenterology, link: Strategies to Combat Physician Burnout

Excerpts:

  • Physician burnout has reached epidemic proportions, with 54.4% of physicians reporting at least one burnout symptom in 2014, an increase from 45.5% 3 years earlier
  • A Medscape survey in 2016 showed a burnout rate among gastroenterologists of 49%, up from 41% the year before
  • Key drivers of burnout are excessive workload, an inefficient environment and
    inadequate support, problems with work life integration, loss of value and meaning in work, and the loss of autonomy, flexibility, and control in work 
    The cost of burnout is high, as these physicians are more likely to leave medicine, retire early, make more medical errors, and have lower patient satisfaction scores

Combating Physician Burnout:

  • Leadership : Having good leaders affects the well-being and satisfaction of physicians in health care organizations
  • Reducing Administrative tasks -scribes, mid-level providers 
  • Control over workflow and work hours
  • “Peer support is crucial, nothing else can replace it.”
  • “Physicians who spend at least 20% of their total effort in an activity that they find most meaningful are at a lower risk for burnout”
  • Self-care: Stress management and mindfulness can reduce burnout

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Physician Burnout Spreading (Part 1)

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Last week, I went to our integrated health care network meeting.  Among the topics was physician burnout.  Lately, this is a “hot” topic with a lot of publicity regarding this increasingly-common problem.

At our meeting, some of the keep points -noted below & in the slides that follow:

  • Physician burnout rate is increasing based on most recent studies
  • Many physicians, 42%, would not choose medicine as their career today
  • Manifestations of burnout include “compassion” fatigue

Physicians may be more at risk for burnout due to the following:

  • Frequent personality characteristics: workaholics, accustomed to delayed gratification
  • Practice aspects: long hours, huge responsibilities

How to Prevent Burnout:

  • Lower stress –recharge with outside activities: hobbies, excursions, charitable work, physical activities, and emotional/spiritual
  • Resources: Stop Physician Burnout, Burnout Prevention Matrix  both by  Dike Drummond

 

Related blog post: Quality Care = Work Satisfaction for Physicians

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Overtreatment –Physician Perspective

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From NY Times: Overtreatment is Common, Doctors Say

An excerpt:

Researchers surveyed 2,106 physicians in various specialties regarding their beliefs about unnecessary medical care. On average, the doctors believed that 20.6 percent of all medical care was unnecessary, including 22 percent of prescriptions, 24.9 percent of tests and 11.1 percent of procedures. The study is in PLOS One.

Reasons for overtreatment that were cited:

  • Fear of malpractice “that fear is probably exaggerated, the authors say”
  • Patient demand
  • Financial incentive

My take: It takes more time explaining why a test/medicine/procedure is a waste of time than to order it; even then, many patients/families are unhappy if the physician does not order the test/medicine/procedure that they think is necessary.  Changing this dynamic is not easy.

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How Healthy are “Healthy Volunteers?”

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A recent study (V Takyar et al. Hepatology 2017; 66: 825-33) examined a total of 3160 subjects enrolled in 149 clinical trials from 2011-2015.  These patients were derived from the NIH Clinical Center, ≥18 years, had ALT and BMI measurements available. Presumed NAFLD (nonalcoholic fatty liver disease) was classified if patient had elevated ALT (≥20 for women and 31≥ for men) along with BMI >25 kg/m-squared.

Key findings:

  • 27.9% (n=881) of these healthy volunteers had presumed NAFLD.  These patients also had higher triglycerides, low-density lipoprotein, cholesterol and HbA1c (P<0.001 for all)
  • The authors note that the presence of these presumed NAFLD as controls “likely” affected the study validity in 10 studies and “probably” affected another 41 studies.

My take: This study shows that patients with presumed NAFLD are often enrolled in research studies as healthy controls.  Furthermore, this can affect study outcomes.

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Lover’s Leap, NC -Appalachian Trail

Erythema Ab Igne

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A few years ago I saw a patient with a similar rash (BF Curtis et al. Gastroenterol 2017; 153: 355-6) and texted a picture to a dermatology colleague who quickly asked me whether my patient was using heating packs/heating pads on her abdomen.

This rash, termed, “erythema ab igne,” develops due to excessive heat exposure.  Also, it has been called “toasted skin syndrome.”  Over time, if heat is not continued to abdomen, in most cases, the skin reverts to normal in this benign asymptomatic condition.