Category Archives: General Health

Politics and Limiting Physician Speech

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A concise review/commentary (WE Parmet et al. NEJM 2016; 374: 2304-7) of Wollschlaeger v Governor of Florida explains how attempts to support the gun lobby are likely imposing unconstitutional limits on the free speech of physicians as well as undermining good health policy.

This law “prohibits physicians from intentionally entering into a patient’s record information about firearm ownership that ‘is not relevant to the patient’s medical care or safety, or the safety of others’; prohibits physicians from asking patients (or for minors, patients’ parents) about firearm ownership unless they believe ‘in good faith’ that ‘information is relevant to patient’s medical care or safety.'”

There are good reasons for physicians to inquire about guns in the homes as there is definitive evidence that a gun in the home increases the risk of death, especially by suicide.  The odds, on average from studies, is a 3-fold risk in homes with guns, but even higher for children and adolescents.

The law is counter productive as well. “Studies to date, as limited as they are, suggest that gun owners so counseled are more likely to change storage practices than to remove guns from their homes.”

While the politics with firearms is heavily influenced by well-funded lobbyists, there are other areas in which there are laws regulating physician speech, including abortion and fracking.

My take: I think it is outrageous that there are laws curtailing a physician’s free speech and efforts to dictate practice based on political philosophy. I hope they will not be upheld.

Related blog post: Can the FDA prohibit free speech? | gutsandgrowth

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NPR: Getting Last-Ditch Experimental (Compassionate Use) Drugs

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NPR: It’s Still Not Easy to Get Last-Ditch Experimental Drugs

An excerpt:

The Food and Drug Administration has reduced an obstacle from its compassionate use policy, streamlining paperwork that physicians must submit to obtain experimental drugs for patients with life-threatening illnesses.

Doctors will now file an application for FDA approval that contains just 11 questions, 15 fewer than the old form. They should be able to complete this new version in 45 minutes, the FDA said. The new form is simpler because it was designed for individual patients, replacing an all-purpose format that had been used by doctors acting on behalf of individuals or groups of patients…

Doctors still must first obtain a letter of authorization from that drug’s manufacturer. The FDA can’t compel drugmakers to grant permission. Manufacturers might reject requests because they’re worried about liability if the drug causes harm or they might consider the drug unsuited for a particular patient.

Balanced Summary of Probiotics & Microbiome Effects on the Brain

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A good updated summary on probiotics from 538 GutScienceWeek:

Do probiotics work? Are they good for me?

This link reviews a good deal of science and has a nice table explaining costs.

Take home message: Probiotics which vary greatly by strain and often lack rigorous production standards may be beneficial for specific conditions like preventing antibiotic-induced diarrhea but probably are not beneficial on an ongoing basis.

The final post in the series looks at How the Gut Affects Your Mood.

While the author explains that there is likely a microbiome effect on the central nervous system as well as some intriguing animal studies, it is too early to know that manipulation of the microbiome will have beneficial effects on neurological/developmental concerns.

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Tick Bites Can Lead to Allergy to Red Meat

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From NBC News: Tick Bite Linked to Rise in Red Meat Allergies

Excerpt:

A tick-related meat allergy has been quietly spreading across the southern and eastern U.S. over the past two decades, but in recent years the number of cases have steadily risen. A tick bite in some people can kick off a sensitivity to red meat that can result in symptoms such as itching, hives, swollen lips and breathing problems. The reaction can sometimes be life threatening. 

Terrific 8th grade graduation speech: 8th grader Nails Impersonations of presidential candidates

What is Missing in Doctors’ Toolkits

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An excellent editorial provides insight into the complex interaction between social problems and health issues.  In this age of widespread information availability, the biggest problems are not solved by knowing everything and memorizing facts.  Solving problems with teamwork and identifying resources are increasingly important.

Here’s the link: NY Times: Giving New Doctors the Tolls They Need

Here’s an excerpt:

But consider the skills I would need to be more effective in just this one clinic session: understanding social issues that contribute to health; marshaling support resources like case management, social work and rehabilitation centers; exploring my patients’ values and goals and encouraging behavior change; leading interdisciplinary care teams; employing new technologies and methods of patient engagement like telemedicine; and appreciating how health systems fit together to influence an individual patient’s care — from home care and community centers to clinics and hospitals. None have traditionally been emphasized in medical education — and, unsurprisingly, doctors in training like myself are often ill-equipped to practice in today’s health care environment…

The new Dell Medical School at the University of Texas, Austin, which enrolls its first class in June, is hoping to revolutionize medical education. The school plans to focus on helping students understand how health systems, communities and social issues contribute to individual health through a variety of innovative methods.

Instead of traditional lecture halls, Dell’s students will learn in collaborative workspaces with a curriculum that emphasizes team-based management of patients. They’ll take weekly classes with pharmacy, nursing, social work and engineering students. Dell’s “Innovation, Leadership and Discovery” program affords students an entire year to pursue projects related to population health and delivery system redesign.

Dell also features a unique collaboration with the university’s College of Fine Arts — known as the Design Institute for Health — to bring design thinking to health care. Here students will learn to think about everything from better hospital gowns and more hospitable hospital rooms to how patients access services online and how to make waiting rooms obsolete.

A representative case, associated with this figure of intestinal histology, of the complexity: a lady with psychosis associated with celiac disease is not adherent with her gluten free diet

A representative case of the complexity referred to in this blog post: NEJM 2016; 374: 1875-83.  This figure of intestinal histology shows damaged surface epithelium.  This is from a lady with new-onset psychosis associated with celiac disease who is not adherent with her gluten free diet

Workplace Violence in Health Care

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A recent review article (JP Phillips. NEJM 2016; 374: 1661-9) discusses the topic of workplace violence against health care workers in the U.S.  Fortunately, this is a topic of which I do not have any expertise. But, on reading, I was fascinated how common this occurs despite a high likelihood of being underreported and largely ignored.

For starters, there are four types of workplace violence.   Type II, in which the perpetrator is a customer or patient of the workplace is thought to be most common.  In hospitals, one survey indicated that this accounted for 93% of all assaults.  Other types of violence include perpetrator who has no association to workplace/employee (type 1), perpetrator who is a current or former employee (type III), or a perpetrator with a personal relationship with employee, such as ex-husband (type IV).

Two areas in medicine experience the highest rates of violence: the emergency room and the psychiatry ward.  In both situations, mental illness, narcotic-seeking behavior, and intoxication may play a role.

Statistics:

  • Nurses and nursing aides are victimized at the highest rates, likely due to increased contact time.  In the Minnesota Nurses’ Study, the annual incidence of verbal and physical assaults was 39% and 13% respectively.
  • ER nurses had a 100% reporting verbal assault and 82.1% reporting physical assault during the previous year.
  • Physicians: one-quarter of ER physicians reported being the targets of physical assault in the previous year.  A much higher rate of verbal threats were noted within the previous 12 months: 75%.
  • Weapons are used in <1% of type II episodes of violence in the health care workplace.

Solutions:

  • There are no clear solutions.
  • The author advocates not overlooking verbal threats.  “The ‘broken windows’ principle, a criminal-justice theory that apathy toward low-level crimes creates a neighborhood conducive to more serious crime, also applies to workplace violence.”  Addressing verbal threats may prevent escalation.
  • To ensure a safe environment, more reporting on this problem is needed along with investigations of potential mitigating strategies.

My take: I have had been yelled at before and I was quite shocked.  This is a topic that is not discussed widely in training and probably should be.

Gibbs Gardens

Gibbs Gardens

Expert Review: GMOs are safe

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Here’s a link to NBC report on National Academies of Science review of Genetically Modified & Genetically Engineered crops: Genetically Modified Crops Are Safe

Here’s an excerpt:

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Here’s a website with full report and data:

National Academies of Science Genetically Engineered Crop Website

Related blog post: War on Science and Genetically-Modified Food | gutsandgrowth

Report also covered by USATODAY:

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John Oliver & Understanding Scientific Studies

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A recent John Oliver segment (~20 minutes) provides a terrific look at how scientific studies need to be evaluated.  Here’s the link: John Oliver Scientific Studies

His main points:

  • Scientists are under pressure to publish and sometimes publish a study with a title to grab interest
  • P-hacking can be done to find statistical significance/correlation that is bogus
  • Reports are often distorted by the media to generate a buzz.  Smelling farts does not prevent cancer (see image below).
  • Some reports extrapolate findings in animals to humans without any studies and without mentioning that these were animal experiments; in addition, most treatments on lab mice do not work for humans.
  • Many media reports do not mention whether the study was industry-funded or the size of the study.  Reports with 10 or 20 people are more likely to lead to false conclusions

Related posts:

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Antibiotic Overuse and Allergic Antibiotic Challenge

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A recent study by Fleming-Dutra K et al (JAMA, May 2016), that has been widely reported, estimates that 1 in 3 antibiotic prescriptions in U.S. are unnecessary.  Here’s a CDC media release link: CDC: 1 in 3 antibiotic prescriptions unnecessary

“About 44 percent of outpatient antibiotic prescriptions are written to treat patients with acute respiratory conditions, such as sinus infections, middle ear infections, pharyngitis, viral upper respiratory infections (i.e., the common cold), bronchitis, bronchiolitis, asthma, allergies, influenza, and pneumonia.  An estimated half of these outpatient prescriptions are unnecessary.”

Some of the downside of unnecessary antibiotics:

  • Allergic reactions and other adverse reactions
  • Infections become more difficult to treat due to increased resistance
  • Expense
  • Clostridium difficile infection

My take: This study’s findings are NOT surprising.  Antibiotics are often prescribed without a clear indication.

Many children are labelled allergic to antibiotics like amoxicillin due to the development of a rash but have not undergone formal evaluation.  However, a recent study (Mill C et al. JAMA Pediatr 2016 Apr 4) shows that an oral provocative challenge that most will be able to tolerate amoxicillin.  Here is a summary of the article by DocAlert (forwarded to me by Mike Hart) -I highlighted in bold the key finding:

In an observational study, researchers offered a graded oral provocation test to all children referred to an allergy clinic in Montreal with suspected allergy to amoxicillin. Children were given 10% of the therapeutic dose of amoxicillin, observed for 20 minutes, then given 90% of the therapeutic dose and observed for at least 1 hour. Parents were instructed to report reactions that occurred the next week.

Of 818 participants (mean age, 1.7 years), 94% tolerated the provocation test and therefore were not allergic to amoxicillin. Of the others, 2% had immediate reactions (within 1 hour of the last dose) — all mild urticaria that resolved with antihistamines — and 4% had nonimmediate reactions (median of 12 hours after the last dose) — all mild maculopapular rash. Only 1 of the 17 children with immediate reactions tested positive on skin prick and intradermal testing 2 to 3 months later.

History of a rash lasting longer than 7 days and parental history of drug allergy were associated with nonimmediate reactions on the provocation test (adjusted odds ratios, 5 and 3, respectively); history of allergic reaction within 5 minutes was associated with immediate reactions (AOR, 10). During 3-year follow-up of children who tolerated the test, 55 received a subsequent full course of amoxicillin and 6 (11%) had nonimmediate reactions. All patients with reactions to amoxicillin tolerated cefixime.

My take (from summary): An oral provocation challenge to confirm either an immediate or nonimmediate allergic reaction to amoxicillin was found to be safe and more accurate than skin testing.

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