Archive for August, 2011

More Good News on Chocolate

Tuesday, August 30, 2011 // Uncategorized

You may have seen this already in the newspaper if you still read those or seen it online/TV.  Here is the Journal Watch summary followed by a link to the original BMJ article and then the previous report on health benefits of chocolate in women.

Meta-Analysis: Chocolate Appears to Be Heart-Healthy
Higher levels of chocolate intake “seem to be associated with a substantial reduction in the risk of cardiometabolic disorders,” a BMJ meta-analysis reports.
Researchers examined seven observational studies, encompassing nearly 115,000 adult participants, that measured chocolate intake and cardiometabolic outcomes. Compared with the lowest level of chocolate consumption, the highest intake was associated with a roughly one third decrease in the risk for any cardiovascular disease or stroke. There was no benefit, however, with regard to heart failure.
The authors offer several cautions with their findings, including the fact that high levels of fat and sugar are found in most commercial preparations of chocolate. They also note that the present evidence only points to an association between chocolate and heart health.

Here is the link to the original British Medical Journal link.http://www.bmj.com/content/343/bmj.d4488.full

Moderate Chocolate Consumption Linked to Lower Risk for Heart Failure in Women

Moderate chocolate consumption might lower a woman’s risk for heart failure (HF), according to a study in Circulation: Heart Failure.

More than 30,000 middle-aged and older Swedish women without histories of diabetes, HF, or myocardial infarction completed food-frequency questionnaires and then were followed for roughly 9 years. During that time, 1.3% were hospitalized for, or died from, HF.

Compared with women who didn’t eat chocolate, those who consumed one to three servings a month had about a 25% reduction in HF risk, while those who consumed one to two servings a week had a 30% risk reduction. Higher intake did not appear to have a protective effect.

The authors point out that chocolate is a good source of flavonoids, which might improve cardiovascular risk factors. They note, however, that chocolate consumed in the U.S. likely contains less cocoa (known to be cardioprotective) than that consumed by women in this study.

So for those who want some justification for their chocolate like they want for their glass of wine, bon appetit!  Don’t overindulge in either.

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Herbal Remedy for the Flu?

Sunday, August 28, 2011 // Uncategorized

Some drugs are derived from plants.  This is a summary from Journal Watch about research from China where Tamiflu (Oseltamivir) was compared against an herbal remedy for the treatment of flu symptoms.  It’s hard to know where this will lead, but other flu drugs are needed to combat the development of resistance.  The abstract from The Annals of Internal Medicine follows.

 

Chinese Herbs as Efficient as Oseltamivir for Shortening Flu Symptoms
Traditional Chinese herbal therapy resolves fever in influenza as quickly as oseltamivir, according to an Annals of Internal Medicine study.
Researchers studied some 400 adults and adolescents in 11 Chinese hospitals who had uncomplicated 2009 H1N1 influenza A. Patients, who remained in the hospital for quarantine purposes and not the severity of their illness, were randomized to one of four groups: maxingshigan-yinqiaosan, oseltamivir, maxingshigan-yinqiaosan plus oseltamivir, or no treatment. (Maxingshigan-yinqiaosan comprises 12 herbs, including ephedra, which is restricted in the U.S.)
The median time to fever resolution was significantly shorter with oseltamivir (20 hours), maxingshigan-yinqiaosan (16), and combination therapy (15) than with no treatment (26). Symptomatic improvement did not differ among the treatment groups. Two patients using maxingshigan-yinqiaosan had nausea and vomiting.
The authors conclude that the herbal treatment can be used as an alternative when oseltamivir is not available.

Here’s the abstract from The Annals of Internal Medicine:

  • Original Research

Oseltamivir Compared With the Chinese Traditional Therapy Maxingshigan–Yinqiaosan in the Treatment of H1N1 Influenza

A Randomized Trial

  1. Chen Wang, MD, PhD;
  2. Bin Cao, MD;
  3. Qing-Quan Liu, MD;
  4. Zhi-Qiang Zou, MD;
  5. Zong-An Liang, MD;
  6. Li Gu, MD;
  7. Jian-Ping Dong, MD;
  8. Li-Rong Liang, MD;
  9. Xing-Wang Li, MD;
  10. Ke Hu, MD;
  11. Xue-Song He, MD;
  12. Yan-Hua Sun, MD;
  13. Yu An, MD;
  14. Ting Yang, MD;
  15. Zhi-Xin Cao, MD;
  16. Yan-Mei Guo, MD;
  17. Xian-Min Wen, MD;
  18. Yu-Guang Wang, MD;
  19. Ya-Ling Liu, MD; and
  20. Liang-Duo Jiang, MD

+ Author Affiliations


  1. From Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, and Beijing Hospital, Ministry of Health, Beijing; Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing; Yantai Infectious Disease Hospital, Shandong; Chengdu Infectious Disease Hospital, Sichuan; Beijing Haidian Hospital, Beijing; Beijing Ditan Hospital, Institute of Infectious Diseases, Capital Medical University, Beijing; Renmin Hospital of Wuhan University; Changxindian Hospital of Fengtai District of Beijing, Beijing; Second Hospital of Chaoyang District of Beijing, Beijing; Second Hospital of Beijing, Beijing; and West China Medical School, West China Hospital, Sichuan University, Sichuan, China.

Abstract

Background: Observational studies from Asia suggest that maxingshigan–yinqiaosan may be effective in the treatment of acute H1N1 influenza.

Objective: To compare the efficacy and safety of oseltamivir and maxingshigan–yinqiaosan in treating uncomplicated H1N1 influenza.

Design: Prospective, nonblinded, randomized, controlled trial. (ClinicalTrials.gov registration number: NCT00935194)

Setting: Eleven hospitals from 4 provinces in China.

Patients: 410 young adults aged 15 to 59 years with laboratory-confirmed H1N1 influenza.

Intervention: Oseltamivir, 75 mg twice daily; maxingshigan–yinqiaosan decoction (composed of 12 Chinese herbal medicines, including honey-fried Herba Ephedrae), 200 mL 4 times daily; oseltamivir plus maxingshigan–yinqiaosan; or no intervention (control). Interventions and control were given for 5 days.

Measurements: Primary outcome was time to fever resolution. Secondary outcomes included symptom scores and viral shedding determined by using real-time reverse transcriptase polymerase chain reaction.

Results: Significant reductions in the estimated median time to fever resolution compared with the control group (26.0 hours [95% CI, 24.0 to 33.0 hours]) were seen with oseltamivir (34% [95% CI, 20% to 46%]; P < 0.001), maxingshigan–yinqiaosan (37% [CI, 23% to 49%]; P < 0.001), and oseltamivir plus maxingshigan–yinqiaosan (47% [CI, 35% to 56%]; P < 0.001). Time to fever resolution was reduced by 19% (CI, 0.3% to 34%; P = 0.05) with oseltamivir plus maxingshigan–yinqiaosan compared with oseltamivir. The interventions and control did not differ in terms of decrease in symptom scores (P = 0.38). Two patients who received maxingshigan–yinqiaosan reported nausea and vomiting.

Limitations: Participants were young and had mild H1N1 influenza virus infection. Missing viral data precluded definitive conclusions about viral shedding.

Conclusion: Oseltamivir and maxingshigan–yinqiaosan, alone and in combination, reduced time to fever resolution in patients with H1N1 influenza virus infection. These data suggest that maxingshigan–yinqiaosan may be used as an alternative treatment of H1N1 influenza virus infection.

Primary Funding Source: Beijing Science and Technology Project and Beijing Nova Program.

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Another Blow to Primary Care

Thursday, August 25, 2011 // Uncategorized

Here’s an article on the impact of budget cuts on training for primary care residencies in Texas.  It helps to retain doctors in Texas if they can get residencies within the state after going to school here. 

The Texas Tribune

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Day 22: State Cuts Mean Fewer Residency Slots in Texas

Enlargephoto illustration by: Todd Wiseman

31 Days 31 Ways


Throughout the month of August, The Texas Tribune is featuring 31 ways Texans’ lives will change come Sept. 1, the date most bills passed by the Legislature — including the dramatically reduced budget — take effect. Check out our story calendar here

Day 22: Lawmakers slash funding for residency programs in Texas, making it even more difficult for the state to meet its growing physician shortage. 

The 2011 legislative session was devastating for graduate medical programs in Texas. Despite strong opposition from organizations like the Texas Academy of Family Physicians and the Texas Medical Association, lawmakers severely cut funding for some residency programs at a time when demand for doctors in Texas is ever-growing.  

Watch the Tribune’s interview with Dr. Bruce Malone, president of the Texas Medical Association, about the impact of these cuts on the state’s ability to maintain an adequate physician training pipeline. He warns that the effect on patient care will not be seen immediately, but cannot be fixed later with an influx of cash. “There is a long queue for that training, so if you cut the people at the beginning of the training process, there’s no way you can make them up quickly,” Malone said.

The Tribune thanks our Supporting Sponsors

 

Since 2006, Texas lawmakers have used Graduate Medical Education funding formulas to provide the state’s medical schools with support to offset the costs of training residents. According to the TMA, the state has never fully funded the program to start with. But with the expiration of some federal funding and the Legislature’s decision to balance the state budget solely through cuts, GME programs will face staggering challenges over the next two years.

The Texas Higher Education Coordinating Board, which administers the funding for these programs, reports that the sharp reductions will affect the following programs:

  • The Family Practice Residency Program was hit with a 72 percent reduction in state support, from $20.2 million in 2010-11 to $5.6 million for the next biennium. This is money used for the education and training of residents in the state’s 26 accredited family practice residency programs. Currently, about 680 residents each receive $14,564. That amount will be reduced to $4,000 per resident. In its analysis of the reduction, THECB says some training programs may be forced to close. At the very least, it may have to reduce the number of resident it can train.
  • The Primary Care Residency Program (which previously served 122 primary care residents in internal medicine, pediatric, and obstetric/gynecology programs) was completely eliminated.
  • Another $570,000 cut from the Graduate Medical Education program will affect 15 independent primary care residency programs and 309 residents.
  • The Physician Education Loan Repayment Program, which pays off the medical school bills of doctors who agree to work in underserved communities, will be reduced by 76 percent, from $23.3 million to $5.6 million. THECB estimates 750,000 citizens will have “decreased or eliminated access to physician services” as a result of the cuts. While the program will honor its commitment to the 172 doctors currently serving in the program, no new doctors will be added. (The Tribune’s Emily Ramshaw’s reported on this issue during the session. See her story here.)

In the bigger picture, Texas is looking at a major shortage of trained doctors at a time when the state holds the distinction of having the fastest-growing population and the highest number of uninsured citizens. TMA credits the state’s 2003 tort reforms as the major reason 21,000 new physicians have moved into the state, but Texas continues to rank 42nd in the number of active doctors per 100,000 residents. In addition, the state is anticipating that federal health care reform will make an estimated 2 million to 3 million new people eligible for Medicaid here. 

**As part of The Texas Tribune’s ongoing effort to explain the fallout from the 2011 regular and special sessions, we encourage you to engage with us and be part of our coverage. Respond to our stories below. Post a comment on our Facebook page. Send photos to our Tumblr site. We may come to you in the future to help us tell the story of how Texas is changing.

 

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Handwashing and School Absenteeism

Wednesday, August 24, 2011 // Uncategorized

School is back in session.  I am preparing for the “back-to-school special”.  The kids get together and start spreading their germs.  They all get colds and then spread it to their siblings and parents.  That’s where I get involved.  At my son’s former school, San Antonio Academy,  the headmaster, John Webster,  had hand sanitizers place on the cafeteria tables and teacher’s desks.  Handwashing is probably better than hand sanitizers, but the latter are more convenient to use.  The following article from the WSJ indicates that their can be real benefits to teaching the kids to wash their hands.

 

  • The Wall Street Journal

 

Schooling Kids to Wash Hands Cuts Sick Days

  •  

By ANN LUKITS

Kids will be heading back to school soon and that means colds, flu and other easily shared infections are bound to pick up. But illness and school absenteeism can be significantly reduced through a program of mandatory hand hygiene, according to a recently published study in the American Journal of Infection Control.

For three months in 2007, 290 Danish schoolchildren age 5 to 15 were asked to disinfect their hands with ethanol-based gel three times a day. The children also were taught proper hand-washing techniques.

Getty ImagesThe school with a hand-hygiene program had 26% fewer missed days than a school with no hygiene program.

RESREPORT

RESREPORT

By contrast, at a nearby school, which served as a control group, parents of 362 pupils in the same age range received written information about a study of hand hygiene and absenteeism, but the kids weren’t required to alter their habits.

The hand-disinfecting group had 567 missed school days and 280 periods of illness, in which students were absent because of a single cause. After adjusting for the different size student bodies, the hand-disinfecting group had 26% fewer missed days and 22% fewer illness periods than the control school.

A year later, the roles were reversed in the two schools and the researchers compared each group’s data against the year-earlier results. At the hand-disinfecting school, which had been the control school in 2007, the number of missed days for the three-month period in 2008 declined 34% from a year earlier, after adjusting for a drop in enrollment. The number of illness periods fell 23% on an adjusted basis.

But among the 2008 control group, the number of missed days and illness periods didn’t change significantly from the previous year, when the group had been disinfecting hands, suggesting that hand-hygiene programs can be habit forming, researchers said. Compliance was estimated at 25%.

Caveat: In 2008, the study manager for the previous year continued to make weekly visits to the control school where she was remembered as the “hand-washing lady.” Her presence plus posters remaining from 2007 may explain the carryover effect, researchers said. Many control-school teachers still reminded children to wash their hands before lunch.

Keep washing those hands.

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Advice for Residents

Sunday, August 21, 2011 // Uncategorized

Here is some advice from a family practice resident at John Peter Smith in Fort Worth for premed students and medical students.  It’s worth reading.

 

The End …

Greg Bratton, MD • August 4th, 2011

Categories: About Residency

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I did it. I graduated.

I remember in sixth grade writing a paper about wanting to grow up to be a doctor, and today, I can truly say, “I did it.”

Graduating from residency, beginning my fellowship, and completing my Family Medicine board exam has made me feel as if I have finally put the punctuation at the end of this journey’s sentence. And despite having 12 more months to learn and refine my skills in Sports Medicine and another board exam on the horizon, I feel free. Free from the feeling of swimming upstream, free from the fear of not making it, and free from not seeing the light at the end of the tunnel.

I know I will face more adversity, self-doubt, and obstacles in the future, but, right now, I am enjoying this feeling of accomplishment. For the first time in a long time, I can take a deep breath and relax.

However, I have to ask myself, “Why was the journey so hard and stressful?” Is it because I am a Type A personality that can make a massage stressful? Is it because the relationship medicine and I have is similar to that of a square peg and a round hole? Or is it because it really is just that difficult? I believe the latter.

So, in an effort to help ease the journey for others, I have compiled a Top 10 list of things I think can make the path to being a doctor a little more enjoyable and/or tolerable.

Here we go…

10. In college, major in something other than pre-med. You will learn enough science in medical school. Choose something like art, philosophy, or dance. It will expand your mind, and you will become well rounded and able to communicate with patients on a “natural” level.
fishing

9. Remember that, ultimately, you are a person first and a doctor second. Patients will relate to you. They will trust in your treatment plans and adhere to your recommendations. Find time to decompress. Take weekends off. Schedule date nights. Get involved with charities. Go fishing. Do something to keep in touch with who you are as a person. Don’t let medicine define you. You were John Doe before medical school, be John Doe after.

8. Date. Get married. Have children. Some say that it is too much to handle with studying, it is too expensive, or it is “just not the right time.” I disagree. I think it makes you better. Plus, no matter how hard of a day you’ve had or how grueling your week is, when you get home, someone is there to take your mind off of it. As a buddy of mine said after having his first son, “there are no more bad days.”

7. Read gossip magazines. After hours of memorizing Robbins Pathology or Grey’s Anatomy, you’ll need something to purge your brain. And what is better than keeping tabs on Lindsay Lohan, Britney Spears, and all the other train wrecks in Hollywood?!?! In addition, it will help you understand the many psychiatric problems you will one day be diagnosing and treating.

6. While at dinner, no matter how many of your classmates or fellow residents are present, DO NOT TALK ABOUT MEDICINE!! It always happens — you go out for a relaxing evening and inevitably start talking about work. Don’t do it! It is not fair to the non-medical professionals listening. Instead, talk about sports, weather, or the latest happenings in US! Magazine (another reason #7 is so important).

5. Periodically, wear normal clothes. I think we all will agree that one of the benefits to working in a hospital is the that you can wear scrubs every day. But remember, scrubs are forgiving; they won’t let you know that you’re not tying the drawstring as tight as you used to. Whether you weigh 150 lbs or 180 lbs, you are still going to wear the same size scrubs. Put on your jeans — they will tell you the truth about your circumference.

4. Exercise. Endorphins are good. Plus it will counteract the late night Cheetos, pizza, and soda consumed while being on-call or studying. And before you say it, there is always time! Just find it.

3. Call home. Talk to your mom and dad, brother and sister, hometown friends. Just because you’re “in medical school” does not mean you get to stop being their son, sibling, or friend. They are your support. Use them, lean on them, involve them. And remember, you are where you are because of them.

2. Keep an open mind while doing 3rd-year rotations. Even if you think you know what you want to do, don’t force yourself to like it. Enter each rotation with an open mind. Go with your gut. I wanted to do orthopedics but found myself “tolerating” the OR, not loving it. Yet, I loved taking care of families, seeing the same patient routinely, and developing relationships with patients. So I chose Family Medicine. Had you told me during my 1st or 2nd year of medical school that I would end up doing primary care, I would have laughed at you. But I love it and can’t imagine doing anything else.

1. Take a deep breath and relax occasionally. Don’t be like me and wait until you receive your diploma to re-center yourself. Do it daily. Know that although the journey is long, it doesn’t have to be rushed. Enjoy the moment. Enjoy the challenge. Realize that you, too, are on your way to achieving your dreams.

And, before you know it, your graduation day will be here.

The next chapter is frightening, but I’m ready, and you will be too. I don’t know where I will practice, what the government has in store for primary care, or how medicine will evolve, but it really doesn’t matter to me much right now. Today, I am happy. Today, I am free.

I did it. I graduated.

I hope you’ve enjoyed reading about my thoughts and experiences during the last year. I’ve definitely enjoyed sharing them.

Greg Bratton

the end

I would add:  Exercise regularly.  It is a great stress reliever.

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New Simvistatin (Zocor) Dosing Guidelines

Thursday, August 18, 2011 // Uncategorized

The following is the latest edition of The Medical Letter which describes the changes in dosing guidelines for the most potent statin available in generic.

New Simvastatin Dosing Recommendations

 
The Medical Letter on Drugs and Therapeutics • August 8, 2011 (Issue 1370) p. 61

The FDA has announced changes in the labeling of simvastatin to reduce the risk of myopathy.(MUSCLE INFLAMMATION). These changes include limiting the use of the 80-mg maximum dose to patients who have been taking it for 12 months or more without evidence of myopathy and new recommendations for use of simvastatin with other drugs.1 Simvastatin is available alone (Zocor, and others) and in combination with ezetimibe (Vytorin) and with niacin (Simcor).

MYOPATHY — The risk of myopathy with simvastatin is closely related to the dose of the drug and even more closely to its concentration in serum.2 In a 7-year randomized trial (SEARCH) in 12,064 patients, the incidence of myopathy (unexplained muscle pain or weakness and a CK >10 times the upper limit of normal) was 0.9% in patients taking 80 mg of simvastatin daily and 0.03% in those taking 20 mg daily. The risk of myopathy was highest in the first year after randomization.3

DRUG INTERACTIONS — Simvastatin is metabolized by CYP3A4. Concomitant use of drugs that inhibit CYP3A4 can increase simvastatin plasma concentrations and the risk of myopathy.2 The new simvastatin label states that its use is contraindicated with strong CYP3A4 inhibitors and with other drugs shown to increase the risk of myopathy when taken with simvastatin. In addition, the label now specifies a maximum simvastatin dose of 10 mg/day when taken with amiodarone, diltiazem or verapamil and 20 mg/day with amlodipine or ranolazine; these drugs have also been shown to increase simvastatin serum concentrations.

CHOICE OF A STATIN — All of the statins available in the US are listed in Table 2. Lovastatin, pravastatin and simvastatin are available generically. High-dose simvastatin (80 mg/d) lowers LDL-C by only about 6% more than 40 mg/d.1 Atorvastatin is more effective in lowering LDL-C, has a well-documented beneficial effect on clinical outcomes, and is expected to become available generically before the end of 2011; in clinical trials, the risk of myopathy with atorvastatin did not appear to be dose-related. Rosuvastatin may be even more effective than atorvastatin in lowering LDL-C, and now has also been shown to improve clinical outcomes; the risk of myopathy with rosuvastatin has been low. Pitavastatin has not been shown to offer any advantage in cholesterol-lowering over statins that are available generically, and clinical outcome studies are lacking.4

CONCLUSION — There is no need to take 80 mg of simvastatin. Patients who fail to achieve their LDL-C goal on 40 mg/day of simvastatin could take atorvastatin or rosuvastatin instead.

1. FDA drug safety communication: new restrictions, contraindications and dose limitations for Zocor (simvastatin) to reduce the risk of muscle injury. Available at www.fda.gov/drugsafety/ucm/htm. Accessed July 29, 2011.

2. Drug interactions with simvastatin. Med Lett Drugs Ther 2008; 50:83.

3. SEARCH Collaborative Group. Intensive lowering of LDL cholesterol with 80 mg versus 20 mg simvastatin daily in 12,064 survivors of myocardial infarction: a double-blind randomised trial. Lancet 2010; 376:1658.

4. Drugs for lipids. Treat Guidel Med Lett 2011; 9:13

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Preventing Respiratory Infections

Sunday, August 7, 2011 // Uncategorized

An ounce of prevention is worth a pound of cure according to Poor Richard’s Almanac.  This fall a new movie is coming out about a pandemic called Contagion.  http://www.fandango.com/movie-trailer/contagion-trailer/135728.  I hope it is better than Hollywood’s previous attempt, Outbreak.

 What mechanisms are effective in preventing the spread of respiratory illnesses?  The following is a summary of an analysis of studies done on this topic.  It concludes that washing ones hands helps to prevent the spread of respiratory infections.  It also showed that simple surgical masks also helped to reduce the spread of disease.  When compared against the more expensive N95 masks which are supposed to be more  effective at filtering out viruses the surgical masks were equally as effective.  They were not able to make any conclusions about the addition of antiviral solutions or antiseptics.

BACKGROUND: Viral epidemics or pandemics of acute respiratory infections like influenza or severe acute respiratory syndrome pose a global threat. Antiviral drugs and vaccinations may be insufficient to prevent their spread.
OBJECTIVES: To review the effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses.
SEARCH STRATEGY: We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL 2010, Issue 3), which includes the Acute Respiratory Infections Group`s Specialised Register, MEDLINE (1966 to October 2010), OLDMEDLINE (1950 to 1965), EMBASE (1990 to October 2010), CINAHL (1982 to October 2010), LILACS (2008 to October 2010), Indian MEDLARS (2008 to October 2010) and IMSEAR (2008 to October 2010).
SELECTION CRITERIA: In this update, two review authors independently applied the inclusion criteria to all identified and retrieved articles and extracted data. We scanned 3775 titles, excluded 3560 and retrieved full papers of 215 studies, to include 66 papers of 67 studies. We included physical interventions (screening at entry ports, isolation, quarantine, social distancing, barriers, personal protection, hand hygiene) to prevent respiratory virus transmission. We included randomised controlled trials (RCTs), cohorts, case-controls, before-after and time series studies.
DATA COLLECTION AND ANALYSIS: We used a standardised form to assess trial eligibility. We assessed RCTs by randomisation method, allocation generation, concealment, blinding and follow up. We assessed non-RCTs for potential confounders and classified them as low, medium and high risk of bias.
MAIN RESULTS: We included 67 studies including randomised controlled trials and observational studies with a mixed risk of bias. A total number of participants is not included as the total would be made up of a heterogenous set of observations (participant people, observations on participants and countries (object of some studies)). The risk of bias for five RCTs and most cluster-RCTs was high. Observational studies were of mixed quality. Only case-control data were sufficiently homogeneous to allow meta-analysis. The highest quality cluster-RCTs suggest respiratory virus spread can be prevented by hygienic measures, such as handwashing, especially around younger children. Benefit from reduced transmission from children to household members is broadly supported also in other study designs where the potential for confounding is greater. Nine case-control studies suggested implementing transmission barriers, isolation and hygienic measures are effective at containing respiratory virus epidemics. Surgical masks or N95 respirators were the most consistent and comprehensive supportive measures. N95 respirators were non-inferior to simple surgical masks but more expensive, uncomfortable and irritating to skin. Adding virucidals or antiseptics to normal handwashing to decrease respiratory disease transmission remains uncertain. Global measures, such as screening at entry ports, led to a non-significant marginal delay in spread. There was limited evidence that social distancing was effective, especially if related to the risk of exposure.
AUTHORS’ CONCLUSIONS: Simple and low-cost interventions would be useful for reducing transmission of epidemic respiratory viruses. Routine long-term implementation of some measures assessed might be difficult without the threat of an epidemic.

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Penny Wise and Pound Foolish

Thursday, August 4, 2011 // Uncategorized

The only way health care reform can succeed is by increasing the number of primary care physicians.  the current impetus for budget cutting reduces the number of residency training programs and this includes general internal medicine residencies.

Residency program cuts could worsen Texas doctor shortage

Posted Saturday, Jul. 30, 2011

By Alex Branch

[email protected]

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‘ & –>The JPS Health Network and other Texas teaching hospitals are bracing for possible deep cuts in federal funding for doctor residency programs, a move some warn would exacerbate the state’s physician shortage.

Deficit reduction proposals call for cutting federal subsidies for graduate medical education by 20 to 60 percent. That’s a potential decrease of about $60 billion over 10 years.

In Texas, federal cuts would follow state funding reductions enacted during the 2011 legislative session. At JPS, state cuts will cost the public hospital almost $800,000, about an 18 percent drop.

Other hospitals had a 25 percent decrease, which could force medical centers to eliminate some training programs, said Dr. Gary Floyd, JPS chief medical officer and chairman of the Texas Medical Association’s Council on Legislation.

“After what the state has done, if the federal government comes in and hits us again with a 30 percent cut, then you’ve cut the funding in half to most centers,” Floyd said. “I think a lot of them would have to think twice about what programs they can and can’t continue.”

Contraction of residency programs is the last thing Texas needs given its shortage of physicians, according to the Association of American Medical Colleges. Texas ranks 42nd nationally in the prevalence of physicians, with about 158 doctors for every 100,000 residents.

Surveys show that 1 in 3 physicians will retire within 10 years, the association says. Meanwhile, about 32 million Americans are expected to gain coverage through healthcare reform, not to mention an influx of aging baby boomers.

“All we see is an increasing demand for more physicians,” said Christiane Mitchell, the association’s director of federal affairs. “To cut a program like this seems contradictory.”

Medicare subsidies

Proposed federal cuts would reduce funding for graduate medical training through smaller Medicare subsidies. Medicare is the main financial resource for medical residencies.

The funding serves two purposes, Mitchell said. One is to pay part of the costs of training a resident doctor because teaching hospitals treat many Medicare patients. The other is to fund a share of the unique services teaching hospitals provide, she said. Those services may include Level 1 trauma centers, burn centers, disaster preparedness and pediatric intensive care units.

“All of those really unique kind of services that, if teaching hospitals didn’t do them for the community, they wouldn’t be there,” Mitchell said. “So if we see reductions in support for both training physicians and providing special services, what we see is an access crisis.”

With deficit reduction plans seemingly changing daily, it is not certain that the cuts will wind up in the final budget deal. But if they do, Texas hospitals could lose about $150 million annually, she said.

Teaching hospitals account for only about 6 percent of hospitals nationally, she said. “Teaching hospitals are carrying the massive burden on these heathcare cuts,” Mitchell said.

JPS has 13 residency programs and 194 resident slots, including a new emergency department program. The largest program is family medicine, with about 85 residents.

The public hospital has not yet determined how it will handle the state’s cuts. Hospital officials will take it up with the board of managers as they finalize the 2011-12 budget, Floyd said. But the losses would likely have to be absorbed initially through the operations budget until the hospital “could get out and try to raise philanthropic funds.”

“It’s going to hurt,” Floyd said. “In these economic times, with our tax base still not stabilized, it is not a good time to be putting anything else into the operations budget.”

Reducing the number of residents the hospital trains would affect the community, he said. About three-quarters of resident doctors start a practice within 100 miles of where they train.

“If we train physicians they are more likely to stay in the state and that benefits the entire Metroplex community,” he said.

The cuts could also affect students graduating from Texas medical schools, including the Texas College of Osteopathic Medicine in Fort Worth. In May 2010, 1,404 students graduated from state medical schools, but Texas had just 1,390 spots for first-year residents.

By 2012, the gap is estimated to be closer to 100.

Stephen Shannon, president of the American Association of Colleges of Osteopathic Medicine, called the current number of residencies “insufficient” in a July 13 letter to President Barack Obama arguing against the cuts.

Nationwide, more than 19,000 students are enrolled in osteopathic medical schools, and many will pursue careers in primary care and practice in rural and underserved communities, Shannon wrote.

“It is very important to recognize that if we are to meet the challenges posed by aging population with high incidences of chronic diseases, we must increase, not decrease, physicians in training,” he said.

Alex Branch, 817-390-7689

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