Category Archives: General Health

The Upside of Too Much Screen Time

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Briefly noted: A recent study (Campbell LB, et al. J Pediatr 2015; 166: 1505-13) has shown a reducing incidence of melanoma in children and adolescents in the U.S. during the 2000-2010 study period.  This study used data from the Surveillance, Epidemiology, and End Results (SEER) cancer registry.  In adolescents, between 2003-2010, the rate of this very rare cancer decreased ~11% per year from 2003-2010.

While the authors do not know the reason for this improved trend, besides speculation about improved used of sunscreen, they also speculate that decreased time spent outdoors may be a factor.  My hunch is that this is a much more likely a contributor to this trend due to the pervasive nature of television, computers and other electronic devices.

Cumberland Island

Cumberland Island

 

PPIs and Associated Heart Risk

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A NY Times review PPIs and Heart Attacks of PLos One study showing an association between PPI usage (eg. prilosec, prevacid, and nexium) and heart attacks -this study does not prove any causality, but is likely to spark some questions. Excerpt:

The widely used drugs known as proton pump inhibitors, or P.P.I.’s — gastric reflux preventives like Prilosec and Prevacid — may increase the risk for heart attack, according to analysis of data involving almost three million people.

A significant limitation of the study, in PLOS One, is that P.P.I. usage may be a marker of a sicker patient population, more subject to heart disease in any case.

Here’s NPR’s take on the same study: Data Dive -Possible Link Between PPIs and Heart Attacks

“The increase in risk is about 16 to 20 percent, depending on the particular drug involved”…

Someone with a low risk of heart attack doesn’t have much to worry about. “If your risk of a cardiovascular event or a heart attack is one in a million, now it is 1.2 in a million,” [Nigham] Shah [one of the authors] says.

“The problem is, it’s very easy to do studies of this sort that lead to conclusions that can be misleading,” says Dr. David Juurlink, a drug-safety researcher at the University of Toronto…

“Having a bad diet, drinking too much alcohol, smoking and all sorts of other things … might lead people to be on a PPI,” Juurlink says. One would expect those people to be at higher risk of heart attack, which leads Juurlink to think the medicine is likely not to blame.”

 

Also noted:

How Does Exercise Improve Your Heart?

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Probably like a lot of people, I presumed that the main way that exercise improved cardiovascular outcomes was due to beneficial effects on weight, serum lipid levels, and adiposity. However, recent research (Liu X et al. Cell Metab 2015; 21: 584-95) has shown a critical role for microRNA miR-222.  This research is summarized by Hill JA (“Braking Bad Hypertrophy” NEJM 2015; 372: 2160-62).

Key points:

  • “Liu et al provide compelling evidence that miR-222 is up-regulated by exercise and serves to brake pathologic cardiac remodeling and release the heart (“braking the brake”) to grow in a beneficial way”
  • Thus, “exercise triggers a robust and adaptive growth response in the myocardium.”
  • “Current evidence suggests that the heart, in response to stress (eg. exercise) can help it retrace its steps and move toward “good” heart growth.”

Bottomline: “Exercise is a powerful medicine with few noorthopedic side effects.”

Related blog posts:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Something Bad is Going to Happen

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A recent commentary (Sonnenberg A, Clin Gastroenterol Hepatol 2015; 13: 820-23) discusses the statistical inevitability of adverse events.  As such, despite our efforts to provide the best care, we should consider how we look at bad outcomes. This article highlights a few common issues in adult gastroenterology, failing to identify colorectal cancer and adverse events at the time of endoscopy.  Using statistical models, the author notes that avoiding all adverse events is nearly impossible.

The broader points for pediatric gastroenterologists/all physicians:

  • Using simple statistics, “adverse events can be expected to occur with a high probability.  Their occurrence is a function of the number of patient encounters and the probability of making mistakes.”
  • “It is a statistical misconception to believe that their rare occurrence would make it possible for an individual gastroenterologist to dodge the bullet.”
  • “It is another statistical misconception to assume that by exerting extreme caution a gastroenterologist also could avert adverse events. The only means to truly reduce adverse events is to avoid patient encounters.”
  • “The physician rarely is given credit for innumerous other patient encounters with good outcomes.  The bad outcome is considered potentially reflective of professional failure or flawed performance. The process ultimately is geared toward showing avoidable mistakes and assigning guilt.  The occurrence of an error, even at its lowest rate, generally is not accepted as a viable reason, although under different circumstances the same reviewers would be willing to accept the less-than-perfect sensitivity or specificity of all diagnostic tests.”
  • “We have to …free ourselves from the illusion that perfection will become achievable through limitless quality assurance.”
  • “Highlighting the statistical nature of adverse events is not meant to belittle the need for continued efforts at improving patient safety and increasing the quality of health care delivery…In a ‘just culture’ of safety and accountability, the occurrence of any error would become an opportunity for learning and improvement rather than retribution or punishment.”

As a personal aside, I took some solace in reading this article and previously in reading the book “Complications: A Surgeon’s Notes on an Imperfect Science” (Complications | Atul Gawande). I clearly remember a few terrible situations that from time to time still fill me with sadness and regret.  I feel better knowing that the mistakes that I have made were not due to a lack of effort or due to a lack of caring.

Take-home message: If you practice medicine, something bad is going to happen. Can we forgive ourselves if our judgement contributed to an adverse event?

Zoo Atlanta

Zoo Atlanta

Short Take on Understanding Bias

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A recent commentary (Rosenbaum L. NEJM 2015; 372: 1959-63) adds a couple of new terms to my lexicon regarding bias.

The author notes that there have been multiple concerns regarding industry-sponsored studies.  For example:

  • Industry-sponsored studies are more likely than government-sponsored ones to have positive results
  • Physicians who attend symposia funded by the pharmaceutical companies subsequently prescribe the featured drugs at a higher rate

While the Physician Payment Sunshine Act requires drug and device companies to disclose payments over $10, she notes that the long-term effects of this transparency are unclear.  With increased transparency, there could be a “phenomenon called ‘moral licensing’: once disclosure gets off your chest, you feel liberated and may feel licensed to behave immorally.  A corollary concern” for the audience, is that this disclosure may be interpreted as a sign of honesty or a sign of expertise rather than as a warning of potential bias.

Two new terms for me:

  • “‘Self-serving bias’: when we stand to gain from reaching a certain conclusion, we unwittingly assimilate evidence in a way that favors the conclusion.”
  • “Bias blind spot“: “Studies suggest that we’re far more likely to think that drug promotions influence our colleagues than that they affect our own behavior.”

The author cautions that anti-industry bias could be detrimental as well.  If having ties to industry lessens the opportunity for individuals to voice their support (or opposition) for new drugs or devices, it could bolster individuals who may “overstate the risks and understate the benefits of these new treatments.”

Related blog posts:

Zoo Atlanta

Zoo Atlanta

What’s More Important: Improving Mortality Rate or Survival Rate? (Hint: It is not a trick question)

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A recent commentary by Aaron E. Carroll in the NY Times explains “Why Survival Rate is Not the Best Way to Judge Cancer Spending.”  If you don’t understand the difference between survival rate and mortality rate, then it is worth a quick read; it explains the concept of “lead-time bias” and “overdiagnosis bias.” Here’s an excerpt:

Mortality rates are determined by taking the number of people who die of a certain cause in a year and dividing it by the total number of people in a population…

Survival rates describe the number of people who live a certain length of time after a diagnosis…

Let’s consider a hypothetical illness, thumb cancer. We have no method to detect the disease other than feeling a lump. From that moment, everyone lives about four years with our best therapy. Therefore, the five-year survival rate for thumb cancer is effectively zero, because within five years of detection, everyone dies.

Now, let’s assume that we develop a new scanner that can detect thumb cancer five years earlier. We prevent no more deaths, mind you, because our therapy hasn’t improved. Everyone now dies nine years after detection instead of four. The five-year survival rate is now 100 percent.

 

Ordering Tests and Good Health

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A provocative article from the NY Times discusses the fact that more testing does not always lead to good health outcomes.  Here’s an excerpt:

A cadre of test skeptics at Dartmouth Medical School specialize in critically examining our test-based approach to well adult care. If you are confused about mammography, colonoscopy or the PSA test for prostate cancer, these folks deserve much of the blame: They have repeatedly demonstrated that these tests and many others do not necessarily ameliorate a healthy person’s health, any more than standardized testing in grade school improves a child’s intellect…

… systems that rate doctors by how well their patients’ blood pressure is managed are likely to invite trouble. Doctors rewarded for treating aggressively are likely to keep doing so even when the benefits begin to morph into harm…One study found that nursing home residents taking two or more effective blood pressure drugs did remarkably badly, with death rates more than twice that of their peers. In another, dementia patients taking blood pressure medication with optimal results nonetheless deteriorated mentally considerably faster.

Yet no quality control system that I know of gives a doctor an approving pat on the head for taking a fragile older patient off meds. Not yet, at least. Someday, perhaps, not ordering and not prescribing will mark quality care as surely as ordering and prescribing do today.

Related blog posts:

Medical Marijuana -Update

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While medical marijuana is not a frequent concern of many pediatric gastroenterologists, our nurses have been getting questions with the recent passage of legislation.  In Georgia, as in many states, marijuana is allowed for certain medical conditions. “Georgia’s medical marijuana law [Haleigh’s Hope Act] does not legalize the production or sale of marijuana, it simply decriminalizes its possession by certain qualified individuals.” –GeorgiaCann Website

in Georgia the patient must suffer from one of these qualifying illnesses:

  1. Cancer, when such diagnosis is end stage or the treatment produces related wasting illness, recalcitrant nausea and vomiting.
  2. Amyotrophic Lateral Sclerosis (ALS), when such diagnosis is severe or end stage.
  3. Seizure disorders related to diagnosis of epilepsy or trauma related head injuries.
  4. Multiple Sclerosis, when such diagnosis is severe or end stage.
  5. Crohn’s Disease
  6. Mitochondrial Disease
  7. Parkinson’s Disease, when such diagnosis is severe or end stage.
  8. Sickle Cell Disease, when such diagnosis is severe or end stage.

While I will not be recommending medical marijuana for my patients, here is a link for How to Legally Obtain Medical Marijuana Oil in Georgia (thanks to AM for information).

Also, Georgia Department of Public Health -Low THC Oil Registry Page

Related blog posts:

From CNN:

University of Chicago

University of Chicago

Complex Medicine and Informed Consent

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A recent review (Grady, C. NEJM 2015; 372: 855-62) stresses some of the emerging challenges of informed consent, particularly in the research setting.

Key points:

  • “Research participants have deficits in their understanding of study information, particularly of research methods such as randomization.”
  • “Reasonable people disagree about the adequacy of the information presented on the consent forms.”

Trends Which Challenge Current Informed Consent Process:

  1. Learning Health Systems. “Should informed consent for these activities be more similar to research informed consent or clinical informed consent?” “Is it ethically acceptable for a patient or research participant to provide consent for an unspecified or broad range of activities?”
  2. Adoption of Complex Technologies, like genetic sequencing. “How should information be presented [with]..complex information, substantial uncertainty…incidental findings, and implications for blood relatives?”
  3. Consent for Future Use of Clinical Data or Biologic Specimens. “How specific does the information provided in the consent process need to be regarding future uses of data or specimens?”
  4. Demographic Changes/Diminished Capacity in Elderly. “Older age, diminished mental capacity, and dementia per se do not indicate that a person is incapable of consenting…there is a need for respectful and efficient tools and processes for assessing capacity.”

Bottomline: In order to treat patients in a respectful manner, continued efforts at addressing these questions are needed to promote informed choices of patients while advancing medical science and clinical care.

Related blog post: According to the study which you would never qualify for …

Empathy vs. Sympathy

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A short animated video from Brene Brown/Katy Davis (thanks to Kayla Lewis for this link) helps explain the difference between empathy and sympthany.  Here’s the link: Short Video on Empathy (the animation is not that great but the message is important)

Key points:

  • Empathy brings people to together and sympathy often drives people apart.
  • Empathy never begins with “at least” …it wasn’t worse
  • Sometimes empathy means saying ‘I don’t know what to say but I’m glad you told me.’

Harrison Ford defines Sympathy in 42 – YouTube.  In the movie “42,” Harrison Ford’s character describes sympathy as being derived from the Greek word to suffer together.  In many cases, sympathy can be difficult to distinguish from pity; this is one reason why empathy can be much more helpful.

Unrelated (but interesting): Comic Version Graphic Points Need for Discussions DNR

Here’s one frame:

From Annal of Intern Medicine Twitter Feed

From Annal of Int Med Twitter Feed