Category Archives: General Health

“Do Unto Others”

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A recent article from NY Times discusses the topic of advance directives and how physicians are likely to choose a “no code” status for themselves rather than heroic measures if faced with a terminal illness.

Here’s a link:  What doctors would choose and an excerpt:

Young doctors… 88.3 percent would choose a do-not-resuscitate or “no code” status. An allow-me-to-die status, in other words.  “Doctors see a lot,” Dr. Periyakoil told me later that day. Resuscitation attempts are so aggressive — likely to break an older patient’s ribs but unlikely to restore them to their previous state of health or function —that after witnessing several, “you know too much and you’re much more wary,” she said.

Perhaps readers here remember a much-circulated web essay by Dr. Ken Murray, a retired family practitioner, called “How Doctors Die.” He claimed that his fellow physicians largely reject the sort of high-tech care they routinely dispense to their patients.

Take-home message: Physicians frequently provide high-intensity heroic measures to many of their patients which they usually would reject for themselves.  Even in pediatrics, frequently parents demand that “everything be done” when many physicians would advise otherwise.

When “All-Natural” Really Isn’t

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A recent tweet from David Kessler provided this link, fooddive.com/news/the-case-…, regarding all-natural products and recent spate of lawsuits:

Here’s an excerpt from “The case against ‘all-natural’:

But how “natural” is the “natural” label? It might be a bit more misleading than you think. The U.S. Food and Drug Administration admits it doesn’t even have a hard-and-fast definition on what the term means. The agency also doesn’t object to a product being labeled as such, so long as “the food does not contain added color, artificial flavors, or synthetic substances.”

However, some consumers just aren’t buying that “all-natural” claim, and there have already been many notable court cases to prove it. Here’s a roundup of five recent lawsuits forcing food producers to cough up cash and remove labels after products didn’t live up to their farm-to-store promise.

Five recent lawsuits -highlighted in article

  • Kashi
  • Nature Valley
  • PopChips
  • Naked Juice
  • Tropicana Orange Juice

In a related post, ClarkHoward.com discusses how labels are misleading:

Here’s the link: 5 Label Tricks

“Food labels like “organic,” “free range,” “all natural,” and “multigrain” don’t necessarily mean what you think.”  He provides specific advice to avoid buying a misleading product.

“ProCESS” for Improvement or Reason for Caution

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“There is no such thing as the world of letters apart from the world of men…The scholar without this vision is a pedant.  He mistakes learning for an end in itself, instead of seeing that it is only a weapon in a wise man’s hands.” (Seth Low, 1890 -quoted in NEJM 2014; 370: 1679).

While sepsis, “the syndrome of dysregulated inflammation that occurs with severe infection,” is not frequent among pediatric gastroenterology patients, it does occur. Pediatric GI patients at risk include patients receiving immunosuppression medications, patients with inflammatory bowel disease, and patients with central lines.  So, it is not simply an academic exercise to understand the efforts to improve sepsis treatment. A recent study and related editorials discuss the role for protocols in treating sepsis, and likely have broader implications [NEJM 2014; 370: 173-76 (editorial-http://nej.md/1hYoAXc ), 1683-93 (article-http://nej.md/1qvKwBc ), 1750-51 (editorial-http://nej.md/1gkt6D2 )].

Overall, sepsis was reported as the 11th leading cause of death in the U.S. in 2010 and was the single most expensive condition treated in hospitals.  Nevertheless, the diagnosis is in part subjective and these statistics rely on insurance claims.

Key points:

  • Policymakers in New York require hospitals to adopt sepsis protocols (“Rory’s regulations”) following the death of a 12 year-old boy who died from unrecognized sepsis.  Other agencies, like the National Quality Forum (NQF), have recommended this as well. The Centers for Medicare and Medicaid is considering whether to adopt the NQF metric.
  • The ProCESS (Protocolized Care for Early Septic Shock) study (31 centers) enrolled 1341 patients (average age 61 years) into 3 randomized separate arms: protocol-based goal-directed therapy bundle, protocol-based standard therapy, and usual care. Conclusion: protocol-based resuscitation did not improve outcomes.
  • Sepsis mandates are not without risks.  Overdiagnosis can lead to unwarranted antibiotics, excessive testing, excessive blood transfusions, diversion of scarce ICU resources, and complications from central line placement.
  • Two more multicenter studies are underway (ARISE and ProMISE) which will further determine the utility of protocoled sepsis care

While the ProCESS trial did not identify improvements in protocol-driven care, most patients (76%) in all three groups received antimicrobials by the time of randomization (mean of ~3 hours).  Thus, early recognition of sepsis with treatment, particularly antibiotics and volume resuscitation, remain critical.  The editorial (pg 1750) imparts some useful advice from Machiavelli: “the physicians say it happens in hectic fever, that in the beginning of the malady it is easy to cure but difficult to detect, but in the course of time, not having been either detected or treated in the beginning, it becomes easy to detect but difficult to cure.”

More Eloquently Stated Concerns Over MOC

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Recently, I stated my concerns over the MOC process: After I Passed The Test | gutsandgrowth

The same issues I discussed are articulated more precisely in a recent editorial, titled “Maintenance of Certification: Beauty is in the Eyes of the Beholder:”

Ann Intern Med. Published online 13 May 2014 doi:10.7326/M14-1014

Here’s the link: http://bit.ly/Centor 

Copy Forward: What Could Go Wrong?

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From GI & Hepatology News: “Copy and paste at your own risk”

Here’s an excerpt:

In medical negligence claims, the accuracy of the patient’s medical record and the credibility of the health care providers are often both at issue, and many times the two go hand in hand. Lawyers representing injured patients love to point out errors in the medical record, whether or not the error caused any patient harm, because – the argument goes – if the medical provider was careless in record-keeping, then chances are he/she was also careless in the treatment at issue…

When data from a prior note in the EHR are copied, little thought or focus is given to context or clarity, and the cobbled-together entry is frequently disorganized and unclear. Worse yet, such copying can result in entering outdated or inaccurate information into the patient’s chart. Even simple errors of this kind can be very damaging. Imagine trying to convince a jury that you are a careful and caring practitioner when it has been pointed out to them that, in your records, your patient’s blood pressure was exactly the same every time she was in your office over the last 5 years. Or that despite the fact that she was experiencing a precipitous, unexplained weight loss, you continued to describe her as morbidly obese. Or that even though her husband died 3 years ago, your records show her “accompanied by spouse” at every visit.

The Bigger Picture -Mammography as an Example

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This week, a commentary makes a strong case for eliminating mammography (N Engl J Med 2014; 370:1965-1967):  “Abolishing Mammography Screening Programs? A View from the Swiss Medical Board”

Here’s a link from the NEJM: nej.md/1hV8q0L

What is fascinating is how ingrained mammography has become in our medical culture and how most individuals believe that mammography is so beneficial.  Take a look at the figure in the link to get a better perspective.  While women think that mammography may save 80 lives out of a thousand screened, according to the commentary, the data suggest that 1 woman may be saved.  The main problem: “for every breast-cancer death prevented in U.S. women over a 10-year course of annual screening beginning at 50 years of age, 490 to 670 women are likely to have a false positive mammogram with repeat examination; 70 to 100, an unnecessary biopsy; and 3 to 14, an overdiagnosed breast cancer that would never have become clinically apparent.”

If a well-established screening measure like mammography is not so beneficial, what else could be on the chopping block?  As noted in a previous blog post (Do you know about the “Choosing Wisely … – gutsandgrowth), even the annual physical exam has been deemed a low-value service.

Another related blog post:

“There is More to Life Than Death” | gutsandgrowth

 

A Leading Cause of Mortality in U.S….

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Being uninsured.  A recent article in Annals of Intern Medicine (2014; 160: 585-93) explored the reduction in mortality associated with expansion of Medicaid.

Key result: “Reform in Massachusetts was associated with a significant decrease in all-cause mortality compared with the control group (−2.9%; P = 0.003, or an absolute decrease of 8.2 deaths per 100 000 adults).”  The control group consisted of similar patients from other states.

An editorial (advbd.co/1lWHfsu) on this subject (from Atul Gawande retweet), notes the following: “The takeaway: Every 830 additional people who got insurance under Massachusetts’ health reforms prevented roughly one death….

A 2012 Urban Institute report estimated that 15.1 million uninsured adults could gain coverage if every state expanded Medicaid. Using the 830 figure from the Massachusetts study, and acknowledging that the state’s coverage wasn’t exactly equivalent to Medicaid, that would translate to 18,193 deaths prevented per year.

For a sense of comparison—that would make the Medicaid coverage gap the number five leading cause of preventable death in the United States”

1 “Medicaid Coverage Gap” based on 2012 estimate; other causes based on 2010 data.

Bottomline: Not having health insurance can be very bad for your health.

Related blog post:

45,000 Unnecessary Deaths Per Year | gutsandgrowth

Questions and Answers about MERS

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Recently two cases of Middle Eastern Respiratory Syndrome (MERS) have been reported in the U.S.  For more information -the following link (thx to Mike Hart) may be useful:  www.cdc.gov/coronavirus/MERS/index.html<http://www.cdc.gov/coronavirus/MERS/index.html

From the CDC: Middle East Respiratory Syndrome (MERS) is viral respiratory illness first reported in Saudi Arabia in 2012. It is caused by a coronavirus called MERS-CoV. Most people who have been confirmed to have MERS-CoV infection developed severe acute respiratory illness. They had fever, cough, and shortness of breath. About 30% of these people died.

So far, all the cases have been linked to countries in the Arabian Peninsula. This virus has spread from ill people to others through close contact, such as caring for or living with an infected person. However, there is no evidence of sustained spreading in community settings.

A Lack of $2.17 Can Cost Thousands More

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An interesting article in the NY Times explains a couple situations in which patients reluctantly admit their lack of financial resources and how this impacts their care.  The article underscores the message that doctors need to find a careful way to find out if patients can afford their medications.

Here’s the link: http://nyti.ms/1fVPzDx  and here’s an excerpt:

His protuberant belly was actually a sign of serious liver disease that had quickly worsened…

“I know how to take the pills, but I can’t buy them,” he said, his eyes refusing to meet mine as he stared at a spot on the hospital’s beige floor…The medicines were crucial to helping him avoid landing in the hospital again, so I went down to the pharmacy to see what the problem might be. “The co-pay is $2.17,” the pharmacist told me matter-of-factly, referring to a white paper bag with a few pill-filled bottles inside…The medications cost less than a subway ticket, but were still more than my patient could afford. If he ended up in the hospital again because he couldn’t take them, the medical costs would be thousands of times greater than $2.17…

A recent report in The American Journal of Medicine that found that one-third of Americans suffering from a chronic illness such as diabetes or high blood pressure said they had trouble affording medications, food or both…

The standard co-payment was $20, the doctor told her, and then gently asked if it would be a problem to pay.  The mother shook her head, but tears were welling up in her eyes. “But we can’t come back in a few months,” she blurted out. “It’s just too expensive.”

Tears rolled down her cheeks, and she looked away as her cheeks flushed. Her daughters sat silently on the exam table, their thin legs swinging back and forth.

I felt the family’s shame and embarrassment, and in retrospect, it seems obvious they lacked enough to eat. Yet we wouldn’t have known they were pressed for funds if our patient hadn’t brought up the issue at the last minute. The pediatrician was able to waive the co-payment, but it was just another short-term fix to a longer-term problem.

Neither doctors nor medical students can solve a patient’s financial problems on the spot. Yet any one of us can be the first to detect a problem. If we’ve done the research, we can help patients get the assistance they need, or at least direct them to social workers, pharmacists and other members of the health care team who can. What we cannot do is fail to ask.

Quitting Smoking Associated with Better Mental Health

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Given the amount of information about the negative consequences of smoking that is currently available, some might say that you would have to be mentally-ill to start smoking.  The good news is that stopping smoking has been associated with improvements in mental health (BMJ 2014; 348: g1151 dii 10.1136/bmj.g1151 -thanks to Mike Hart for this reference).  Free full-text BMJ article PDF

From Abstract:

Design Systematic review and meta-analysis of observational studies.

Eligibility criteria for selecting studies Longitudinal studies of adults that assessed mental health before smoking cessation and at least six weeks after cessation or baseline in healthy and clinical populations.

Results 26 studies that assessed mental health with questionnaires designed to measure anxiety, depression, mixed anxiety and depression, psychological quality of life, positive affect, and stress were included…. the standardised mean differences (95% confidence intervals) were anxiety −0.37 (95% confidence interval −0.70 to −0.03); depression −0.25 (−0.37 to −0.12); mixed anxiety and depression −0.31 (−0.47 to −0.14); stress −0.27 (−0.40 to −0.13). Both psychological quality of life and positive affect significantly increased between baseline and follow-up in quitters compared with continuing smokers 0.22 (0.09 to 0.36) and 0.40 (0.09 to 0.71), respectively). There was no evidence that the effect size differed between the general population and populations with physical or psychiatric disorders.

Conclusions Smoking cessation is associated with reduced depression, anxiety, and stress and improved positive mood and quality of life compared with continuing to smoke. The effect size seems as large for those with psychiatric disorders as those without. The effect sizes are equal or larger than those of antidepressant treatment for mood and anxiety disorders.

Figure 2 shows the relationship of the individual studies and the mental health outcomes.  In every study except one, there was improvement in those who quit smoking, though many of the studies had confidence limits that indicated that the results did not meet statistical significance.

Bottomline: This study indicates that quitting smoking can improve rather than worsen mental health.