Archive for December, 2011

The Road Less Traveled

Saturday, December 31, 2011 // Uncategorized

 A lot has been written about this generation of medical students and how important they value lifestyle.  They want to have time to enjoy their families and pursue leisure activities.  The most competitive residencies are those that allow regular hours and allow them to pay off their student loans which average about $200,000 per student.  The following is one physician’s experience in primary care, the road less traveled. Perspective

The Road Less Traveled

Diane R. Fingold, M.D.

N Engl J Med 2011; 365:2449-2451December 29, 2011

Article

I worry that the primary care physician is a dying breed. Though it was once considered the noblest profession, U.S. medical students today believe the work is too hard, the hours too long, the pay too low. So they’re choosing to hit the “ROAD” — the high-paying specialties of radiology, ophthalmology, anesthesia, and dermatology.

But if you think being a primary care doctor is hard, meet Mary. Not many people have it harder than Mary. She always leaps to mind when I consider how our health care system fails our patients — and why I chose primary care. I’m Mary’s doctor, and though I care deeply about her, seeing her name on my schedule evokes mixed feelings: irritation that I’ll be an hour behind schedule the rest of the day; trepidation over the 50-50 chance she’ll need to be admitted, disrupting my busy day; and fear about intractable social problems.

Boston Irish, Mary has striking white hair and mischievous blue eyes; she’s feisty, funny, and utterly determined. Her neighborhood has seen generations of immigrants; its streets are lined with two-family homes and historic red brick churches, and there are pubs on every corner. Born and raised not far from her current apartment, she was stricken with rheumatic fever as a young girl. She remembers her youth as plagued by poor health, yet she graduated from high school, worked, married, and raised three children.

But the early heart infection took a toll. By her mid-40s, Mary had an increasingly calcified mitral valve, an enlarging heart, and a damaged conduction system that caused atrial fibrillation and hypertension. Then came the stroke and a life forever changed. The paralysis of her right side was devastating enough, but she was also left unable to speak. Ultimately, with great difficulty, she began to utter a few simple words. Overwhelmed by her disabilities and dependent on others as never before, Mary saw her losses mount when her husband, unable to cope with her situation, left her.

Soon thereafter, Mary’s creatinine level began to climb. No diabetes, no new meds, no obvious explanation for her failing kidneys. She saw a nephrologist and had innumerable blood and urine tests and finally a renal biopsy — the challenge of each experience heightened by the difficulty of communication and her loss of mobility. Eventually, she received a diagnosis of focal glomerular sclerosis. The kidney deterioration couldn’t be stopped, and she became overloaded with fluid and toxins. Mary had multiple hospital admissions for congestive heart failure and was facing the prospect of dialysis. An attempt at mitral valvuloplasty bought her a little time, but the admissions soon resumed.

Then hemodialysis began. Consider the logistics of requiring a wheelchair, being unable to communicate over the phone, and needing to get to dialysis appointments three times a week. Add to the mix that Mary was unemployed, estranged from her children, took 16 medications daily, and also had to get to appointments for physical, occupational, and speech therapy — plus regular visits to the nephrologist, the cardiologist, and me. Somehow, she did it: her tenacity is astounding.

Finally, Mary got a lucky break: a cadaveric kidney that was a close match. She had a rocky perioperative course but ultimately a good outcome. Mary’s joy at not having to return to dialysis was palpable; she strained to utter the words, “Thanks, thanks!”

Mary’s pharmacy is one of few that still have the personal touch — Mary receives her pills in blister packs weekly by mail. There’s a real pharmacist I can speak to on the phone; he knows Mary well, knows all her meds, and is there every day, so whenever I adjust Mary’s Lasix dose, I can call him and get an extra blister pack sent to her the next day. It seems like a gift from above.

Traveling by wheelchair down the sidewalk of her bustling neighborhood is part of Mary’s daily routine. Draped over the back of her wheelchair, she keeps a bag containing all her medications and a book with her doctors’ phone numbers and upcoming appointments; it makes her feel secure. But one day, a desperate stranger found it too tempting: a disabled woman, all alone, with that bag just dangling for the taking. In a moment, it was gone. Mary felt like her world was gone, too.

“I understand she’s not due for her medications yet, but as I just explained to you, her medications were stolen.” I don’t know how many people I spoke to, but no one seemed to be able to fix the problem. Without her Lasix, Mary would probably be in heart failure in 48 hours, and her immunosuppressants and prednisone prevent acute rejection of her transplanted kidney. Finding someone who understood the seriousness of the situation and could help seemed impossible. Even her pharmacist was willing to give her only a few days’ supply until Mary sorted things out with the insurance company — our government. But how could she “sort things out” when she couldn’t even speak? Somehow, miraculously, I persuaded someone to replace Mary’s pills.

But for Mary, such miracles are rare. She arrives at my office for a follow-up visit, clearly distraught. She struggles through tears to choke out a few words (“darn, thanks, yes”) that don’t convey what she needs to say. She points to the phone, “You want me to call someone?” I ask. She nods emphatically. “Who? A relative? One of your specialists? Do you need a refill on one of your medications?” She lurches forward. I’m on the right track. “Which one?” I ask. She frowns. Off track. “OK, you don’t need a refill; what do you need?” Of course I know she can’t answer that. And if I’m feeling this frustrated, how does Mary feel every hour of every day? How does she go on?

I finally figure out that she wants me to call her pharmacist. Without knowing why, I dial the number. “I was expecting your call,” he says. There’s a “problem” with Mary’s treatment. She’s been dropped from Medicaid and is no longer eligible for her medications. My heart sinks. Mary’s eyes are filled with fear — it’s as bad as she thinks. Again, the pharmacist offers a few days’ supply until Mary can straighten things out. I want to scream, “But she can’t speak!”

I talk to social workers. Connected with every department in the vast Medicaid bureaucracy, I repeat the story, getting variations on a standard response: “That shouldn’t have happened, but I’m not sure how to reverse the problem.” Luckily, the pharmacist is flexible about “a few days,” and after about a month, Mary is back on the Medicaid logs. It was a fluke, I’m told — a simple error that could send a life into a tailspin.

Mary’s life is filled with such stories, but she musters awe-inspiring strength and determination for each challenge. At times, it does feel too hard to be Mary’s doctor. But it also has priceless rewards — which those medical students on the ROAD don’t yet understand and may never get to experience. Every time Mary rolls into the emergency department, the overworked housestaff quickly tire of being unable to “get the story” from her. They just give her a squirt of Lasix or an antibiotic and head for the door. I understand their frustration. But what about Mary?

I get the call and head over to the ED. As I pull back the curtain, a smile of recognition spreads over Mary’s face. She can relax now. She knows I care, that I’ll figure out her story and make sure the ED docs know all her meds, allergies, and complications; I’ll let her specialists know she’s here. She knows that if her medicines change, I’ll contact her pharmacy to ensure she gets a new blister pack. She lies back and breathes more comfortably.

And at times like this, I recognize my deep satisfaction with the road I’ve chosen to travel.

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

Source Information

From Harvard Medical School and Massachusetts General Hospital — both in Boston.

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Who Should Take Vitamin Supplements?

Monday, December 26, 2011 // Uncategorized

The following is the latest recommendation from The Medical Letter, a publication from a nonprofit, that analyzes new medications and advises on the use of older medication.  When they last published recommendations on this subject, they concluded that there was no evidence that taking vitamin supplements was of benefit.  Now their recommendations are a little different.

Who Should Take Vitamin Supplements?

 

The Medical Letter on Drugs and Therapeutics • December 12, 2011 (Issue 1379) p. 101
Important Copyright Message: The Medical Letter® publications are protected by US and international copyright laws. Forwarding, copying or any distribution of this material is prohibited. Sharing a password with a non-subscriber or otherwise making the contents of this site available to third parties is strictly prohibited. By accessing and reading the attached content I agree to comply with US and international copyright law and these terms and conditions of The Medical Letter, Inc.

Many patients ask their healthcare providers whether they should take vitamins. Since the last Medical Letter article on this subject,1 more data have become available on the benefits and risks of taking vitamins.

VITAMIN E — Vitamin E in food, which is mostly gamma-tocopherol, acts as an antioxidant. Vitamin E in supplements is mostly alpha-tocopherol, which may block the antioxidant activity of gamma-tocopherol and may have a pro-oxidant effect in vivo.2 High doses of vitamin E may interfere with vitamin K metabolism and platelet function.

Effect on Mortality – A meta-analysis of 26 clinical trials including 105,065 subjects found that supplementation with vitamin E alone or in combination with beta-carotene and vitamin A was associated with an increased risk of death.3

Pregnancy – A meta-analysis of 9 trials involving 19,810 pregnant women found that vitamin E and C supplementation was associated with an increased risk of gestational hypertension and premature rupture of membranes.4 A randomized, double-blind trial in 10,154 pregnant women found that 400 IU of vitamin E and 1000 mg of vitamin C started at any time between weeks 9-16 of gestation did not decrease the risk of preeclampsia.5

Stroke – A meta-analysis of 13 randomized, controlled trials in 166,282 patients found that supplementation with vitamin E at any dose was not beneficial in preventing any type of stroke.6 Another meta-analysis of 9 trials in 118,765 patients found that vitamin E increased the risk of hemorrhagic stroke by 22% and reduced the risk of ischemic stroke by 10%.7

Cardiovascular Events and Cancer – Three randomized trials, one in 14,641 men and two in 39,876 and 8171 women found that supplementation with vitamin E did not reduce the risk of major cardiovascular events or cancer.8-10 A randomized, controlled trial in 35,533 men found that after 7 years (5.5 years on supplements and 1.5 off supplements), men taking vitamin E alone (400 IU/day) had a statistically significant 17% increase in the risk of prostate cancer, compared to those taking a placebo.11

VITAMIN A AND BETA-CAROTENE — Vitamin A and beta-carotene, a potent source of vitamin A, are antioxidants, but may also have pro-oxidant effects in vivo. Multivitamin preparations usually contain 1000 to 10,000 IU (0.6 to 6 mg) of beta-carotene; betacarotene supplements usually contain 12-15 mg.

Cancer – A double-blind, randomized, placebo-controlled trial in 18,314 smokers, former smokers and workers exposed to asbestos found that 30 mg/day of a beta-carotene supplement plus 25,000 IU/day of vitamin A for an average of 4 years increased the incidence of lung cancer.12 A placebo-controlled trial in Finnish smokers found that 20 mg/day of a beta-carotene supplement significantly increased the risk of lung cancer.13 A prospective study that analyzed serum vitamin A levels in 29,104 men found that higher serum vitamin A concentrations were associated with an increased risk of prostate cancer.14

VITAMIN D — Many elderly people, especially those with dark skin, have inadequate amounts of vitamin D because of limited exposure to sunlight, decreased synthesis of vitamin D in the skin, and decreased absorption and activation of the vitamin. The latest US recommendations for the minimum daily requirement of vitamin D (vitamin D3 is preferred), based on amounts that have slowed the rate of bone loss, are 600 IU for males and females 1-70 years old, and 800 IU for men and women over 70. Persons infrequently exposed to the sun may need 800-1000 IU of vitamin D daily, and many experts now recommend 800 IU or more for all postmenopausal women.15 Elderly people who do not expose themselves to sunlight will need to take supplements to achieve adequate serum levels of vitamin D.

Fractures – Some experts have suggested that serum levels of 25-OH vitamin D ≥30 ng/mL may be desirable in older adults to help prevent fractures and falls.16 A meta-analysis of 7 randomized, controlled trials in men and women ≥60 years old indicated that a minimum of 700 IU/d of vitamin D3 , with or without calcium supplementation, could decrease the risk of nonvertebral fractures.17 Another meta-analysis in men and women ≥50 years old reported that use of calcium alone or calcium plus vitamin D reduced fractures of all types, especially with calcium doses ≥1200 mg/d and vitamin D doses ≥800 IU/d.18

A double-blind trial in 2256 women ≥70 years old at high risk for fracture found that a single 500,000-IU dose of vitamin D3 taken once a year for 3-5 years increased the risk of fractures and falls, compared to placebo.19

VITAMIN C — Dietary levels of about 300-400 mg/day of vitamin C maintain body pools of the vitamin. One 8-oz glass of orange juice contains about 100 mg of vitamin C.

Cancer – Vitamin C 500 mg/day plus 400 IU of vitamin E every other day for a mean follow-up period of 8 years in men ≥ 50 years old failed to reduce the risk of cancer, compared to placebo.20 Similar findings have been reported in women.10

Cardiovascular Disease – The Physicians’ Health Study II found no beneficial effect of vitamin C supplementation (in combination with vitamin E) on the primary or secondary prevention of cardiovascular disease.8

Upper Respiratory Infection – A meta-analysis of 30 trials involving 11,350 subjects showed that prophylactic use of ≥200 mg/day of vitamin C did not significantly reduce the risk of developing a cold or the severity of cold symptoms.21

Toxicity – High doses of vitamin C (more than 1 gram) are poorly absorbed, cause diarrhea, and could increase urinary oxalate excretion to a level that might cause kidney stones in people with pre-existing hyperoxaluria.

VITAMIN B12 — Vitamin B12 deficiency, diagnosed by elevated serum concentrations of methylmalonic acid with or without elevated serum homocysteine and low serum B12 concentrations, is common in older patients. Atrophic gastritis, which affects 10-30% of older people, results in inability to absorb vitamin B12 from food, with absorption of crystalline vitamin B12 usually left intact. Vitamin B12 can be taken orally or sublingually, injected IM once monthly, or sprayed intranasally.22

FOLATE — The standard US diet provides 50-500 mcg of absorbable folate per day, but the bioavailability of folate in mixed diets varies. Folic acid in supplements is about twice as bioavailable as folate in food. All enriched cereal grains sold in the US contain 140 mcg of folic acid per 100 g of grain; estimates suggest that this fortification increases folic intake by about 215-240 mcg/day. Even this amount, however, may be inadequate for prevention of neural tube defects, which occur early in pregnancy before most women know that they are pregnant.

Neural Tube Defects – Supplementing the diet of women of child-bearing age with 400 mcg of folic acid per day, the amount contained in most multivitamin preparations, has decreased the incidence of neural tube defects in their offspring.23

Toxicity – High doses of folic acid can mask vitamin B12 deficiency, permitting progression of neurologic disease.

VITAMIN B6 – Cardiovascular Disease – A randomized, double-blind, placebo-controlled trial in 5422 women with, or at risk for, cardiovascular disease found that a combination of 2.5 mg of folic acid, 50 mg of vitamin B6 (pyridoxine) and 1 mg of vitamin B12 for 5 years reduced homocysteine levels, but did not reduce the risk of stroke.24 Other trials have also failed to demonstrate that vitamin B6 supplementation, in addition to folate and vitamin B12, reduces the risk of stroke or any other cardiovascular event.25,26

Cancer — A meta-analysis of 12 studies found that vitamin B6 supplementation reduced the risk of colorectal cancer,27 but 2 randomized, double-blind trials found no association between vitamin B6 supplementation alone and a reduction in the risk of any cancer.28

MULTIVITAMINS — A study in 38,772 women (mean age 61.6 years) found that self-reported use of at least one supplement containing either multivitamins, vitamin B6, folic acid, iron, magnesium, zinc or copper was associated with an increased mortality rate.29

BARIATRIC SURGERY — A study in 58 patients who underwent bariatric surgery found that serum levels of vitamin B12, vitamin C and beta-carotene remained low even with supplementation.30 Bariatric surgery patients are also at risk for deficiencies in folate and vitamins B1, A, D and K.31

CONCLUSION — In healthy people living in developed countries and eating a normal diet, the benefit of taking vitamin supplements is well established only to ensure an adequate intake of folic acid in young women and of vitamins D and B12 in the elderly. There is no good reason to take vitamins A, C or E routinely. No one should take high-dose beta-carotene supplements. Long-term consumption of any biologically active substance should not be assumed to be free from risk.

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Negative Neti News

Saturday, December 24, 2011 // Uncategorized

Neti pots are a popular device used for irrigating the sinuses with saline.  I have never been skilled enought to master their use and have relied on commerical saline bottles such as Ocean Spray.  The saline is mixed using sterile or boiled water.  In Louisiana, there have been reports of two fatal infections caused by using tap water instead.

North Louisiana Woman Dies from Rare Ameba Infection

DHH warns residents about improper neti pot use

Tuesday, December 6, 2011  |  Contact: Bureau of Media & Communications (225) 342-7913 or (225) 252-3579 (cell)

Baton Rouge—The Louisiana Department of Health and Hospitals is warning residents about the dangers of the improper use of neti pots. The warning follows the state’s second death this year caused by Naegleria fowleri, the so-called brain-eating ameba. A 51-year-old DeSoto Parish woman died recently after using tap water in a neti pot to irrigate her sinuses and becoming infected with the deadly ameba. In June, a 20-year-old St. Bernard Parish man died under the same circumstances. Naegleria fowleri infects people by entering the body through the nose. A neti pot is commonly used to irrigate sinuses, and looks like a genie’s lamp.

“If you are irrigating, flushing, or rinsing your sinuses, for example, by using a neti pot, use distilled, sterile or previously boiled water to make up the irrigation solution,” said Louisiana State Epidemiologist, Dr. Raoult Ratard.  “Tap water is safe for drinking, but not for irrigating your nose.”  It’s also important to rinse the irrigation device after each use and leave open to air dry.

Naegleria fowleri infection typically occurs when people go swimming or diving in warm freshwater lakes and rivers. In very rare instances, Naegleria fowleri infections may also occur when contaminated water from other sources (such as inadequately chlorinated swimming pool water or heated tap water less than 116.6 degrees Fahrenheit) enters the nose when people submerge their heads or when people irrigate their sinuses with devices such as a neti pot. You cannot be infected with Naegleria fowleri by drinking water.

Naegleria fowleri causes the disease primary amebic meningoencephalitis (PAM), a brain infection that leads to the destruction of brain tissue. In its early stages, symptoms of PAM may be similar to symptoms of bacterial meningitis.

Initial symptoms of PAM start one to seven days after infection. The initial symptoms include headache, fever, nausea, vomiting, and stiff neck. Later symptoms include confusion, lack of attention to people and surroundings, loss of balance, seizures, and hallucinations. After the start of symptoms, the disease progresses rapidly and usually causes death within one to 12 days.

Naegleria fowleri infections are very rare. In the 10 years from 2001 to 2010, 32 infections were reported in the U.S. Of those cases, 30 people were infected by contaminated recreational water and two people were infected by water from a geothermal drinking water supply.

The Louisiana Department of Health and Hospitals strives to protect and promote health statewide and to ensure access to medical, preventive and rehabilitative services for all state citizens. To learn more about DHH, visit http://www.dhh.louisiana.gov. For up-to-date health information, news and emergency updates, follow DHH’s blog, Twitter account and Facebook.

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Distracted Doctoring

Sunday, December 18, 2011 // Uncategorized

We’ve heard a lot about distracted driving, but this is the first time I had heard of distracted doctoring.  Documenting the encounter between the patient and the doctor is important.  There is a push to record these electronically, so the records are more legible.  Electronic medical records are touted as a means of improving the quality of care.  Writing or tapping on an electronic tablet, typing on a keyboard or dictating into a voice recorder are newer means  of recording details of the encounter.  Patients may find these newer methods of documentation as intrusive.  One of my patient scomplained that a consultant that he had seen was more preoccupied with his electronic tablet than he was with their visit.  Computers and hand held devices are also used to access the most recent medical information to assist in making decisions about patient care, but there is a temptation to use them to check their emails or surf the web while seeing patients.

Here is the summary from Journal Watch.  Following that is the original article from the New York Times.

‘Distracted Doctoring’: Mobile Devices Coming Between Patients and Their Providers

 

Healthcare providers are using computers and mobile devices more and more often — but not necessarily to better treat their patients. In an article on “distracted doctoring,” the New York Times describes surgeons making personal calls during operations, physicians shopping online in the ICU, and bypass technicians texting during procedures.Doctors, particularly younger ones, say they feel mounting pressure to check their devices for the “latest, instantly accessible information,” the Times reports. But even when technology is used to access patient data, the “iPatient” — the patient on the screen — can end up getting all of the attention, leaving the real patient by the wayside, cautioned Dr. Abraham Verghese of Stanford University. Dr. Charles Prober, also of Stanford, said, “Devices have a great capacity to reduce risk. But the last thing we want to see, and what is happening in some cases now, is the computer coming betweeen the patient and his doctor.”

As Doctors Use More Devices, Potential for Distraction Grows

Doug Benz for The New York Times

“My gut feeling is lives are in danger,” said Dr. Peter J. Papadakos, of the University of Rochester Medical Center.

By
Published: December 14, 2011
 

Hospitals and doctors’ offices, hoping to curb medical error, have invested heavily to put computers, smartphones and other devices into the hands of medical staff for instant access to patient data, drug information and case studies.

 

But like many cures, this solution has come with an unintended side effect: doctors and nurses can be focused on the screen and not the patient, even during moments of critical care. And they are not always doing work; examples include a neurosurgeon making personal calls during an operation, a nurse checking airfares during surgery and a poll showing that half of technicians running bypass machines had admitted texting during a procedure.

This phenomenon has set off an intensifying discussion at hospitals and medical schools about a problem perhaps best described as “distracted doctoring.” In response, some hospitals have begun limiting the use of devices in critical settings, while schools have started reminding medical students to focus on patients instead of gadgets, even as the students are being given more devices.

“You walk around the hospital, and what you see is not funny,” said Dr. Peter J. Papadakos, an anesthesiologist and director of critical care at the University of Rochester Medical Center in upstate New York, who added that he had seen nurses, doctors and other staff members glued to their phones, computers and iPads.

“You justify carrying devices around the hospital to do medical records,” he said. “But you can surf the Internet or do Facebook, and sometimes, for whatever reason, Facebook is more tempting.”

“My gut feeling is lives are in danger,” said Dr. Papadakos, who recently published an article on “electronic distraction” in Anesthesiology News, a journal. “We’re not educating people about the problem, and it’s getting worse.”

Research on the subject is beginning to emerge. A peer-reviewed survey of 439 medical technicians published this year in Perfusion, a journal about cardio-pulmonary bypass surgery, found that 55 percent of technicians who monitor bypass machines acknowledged to researchers that they had talked on cellphones during heart surgery. Half said they had texted while in surgery.

About 40 percent said they believed talking on the phone during surgery to be “always an unsafe practice.” About half said the same about texting. The study’s authors concluded, “Such distractions have the potential to be disastrous.”

Doctors and medical professionals have always faced interruptions from beepers and phones, and multitasking is simply a fact of life for many medical jobs. What has changed, doctors say, especially younger ones, is that they face increasing pressure to interact with their devices.

The pressure stems from a mantra of modern medicine that patient care must be “data driven,” and informed by the latest, instantly accessible information. Annual investment in gadgets and other technology by hospitals and doctors has soared into the billions of dollars.

By many accounts, the technology has helped reduce medical error by, for example, providing instant access to patient data or prescription details.

Dr. Peter W. Carmel, president of the American Medical Association, a physicians group, said technology “offers great potential in health care,” but he added that doctors’ first priority should be with the patient.

Indeed, doctors and nurses face growing pressures to listen carefully to patients, provide customer service and show empathy as they look for subtle cues that might explain an illness.

“The computer has become a good place to get a result, communicate with other people,” said Abraham Verghese, a doctor and professor at the Stanford University Medical Center and a best-selling medical writer. “In the interest of preventing medical error, it’s a good friend.”

At the same time, he said, the wealth of data on the screen — what he frequently refers to as the “iPatient” — gets all the attention.

“The iPatient is getting wonderful care across America,” Dr. Verghese said. “The real patient wonders, ‘Where is everybody?’ ”

It is hard to know the precise impact that distracted doctoring has on patient care, because it is hard to measure. But at least one example puts the risks in sharp relief.

Scott J. Eldredge, a medical malpractice lawyer in Denver, recently represented a patient who was left partly paralyzed after surgery. The neurosurgeon was distracted during the operation, using a wireless headset to talk on his cellphone, Mr. Eldredge said.

 
“He was making personal calls,” Mr. Eldredge said, at least 10 of them to family and business associates, according to phone records. His client’s case was settled before a lawsuit was filed so there are no court records, like the name of the patient, doctor or hospital involved. Mr. Eldredge, citing the agreement, declined to provide further details.

Others describe multitasking as relatively commonplace.

“I’ve seen texting among people I’m supervising in the O.R.,” said Dr. Stephen Luczycki, an anesthesiologist and medical director in one of the surgical intensive care units at Yale-New Haven Hospital. He said he had also seen young anesthesiologists using the operating room computer during surgery.

“It is not, unfortunately, uncommon to see them doing any number of things with that computer beyond patient care,” Dr. Luczycki said, including checking e-mail and studying or entering logs on a separate case. He said that when he was in training, he was admonished to not even study a textbook in surgery, so he could focus on the rhythm and subtleties of the procedures.

When he uses computers in the intensive care unit, he regularly sees what his colleagues were doing before him.

“Amazon, Gmail, I’ve seen all sorts of shopping, I’ve seen eBay,” he said. “You name it, I’ve seen it.”

Dr. Luczycki is also a huge fan of technology’s positive impact on medicine. So, too, is Dio Sumagaysay, administrative director of 24 operating rooms at Oregon Health and Science University hospitals, even though he has heard about or witnessed instances of people using devices during critical moments.

In early 2010, he heard several complaints that doctors or nurses were using their phones to check or send e-mails even though they were part of a team intubating a patient before surgery.

Mr. Sumagaysay established a policy to make operating rooms “quiet zones,” banning any activity that was not focused on patient care. He later had to reprimand a nurse he saw checking airline prices using an operating room computer during a spinal operation.

Medical professionals say young doctors can be particularly susceptible to distraction because they have grown up being constantly connected.

At Stanford Medical School, for example, all students now get iPads, which they use to read medical texts and carry with them in hospitals but are also admonished not let get in the way of their work.

“Devices have a great capacity to reduce risk,” Dr. Charles G. Prober, senior associate dean for medical education at the school, said. “But the last thing we want to see, and what is happening in some cases now, is the computer coming between the patient and his doctor.”

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A New Flu

Sunday, December 11, 2011 // Uncategorized

This is a report from Pro Med Digest, a” bug watch” bulletin, that I get several times a day about a new strain of flu.  This strain is  usually transmitted from  contact with pigs, is not very infective, is not very virulent and is responsive to antiviral meds. Since it is related to older strains, people who have been immunized over the years may have some immunity to the virus.

CDC confirms 2 human infections with novel influenza viruses
– ————————————————————
The Centers for Disease Control and Prevention (CDC) have confirmed 2
cases of human infection with 2 different novel influenza A viruses in
different states. Both patients have fully recovered. While the
viruses infecting both patients have been found in US swine and some
of the prior human infections with these viruses have been associated
with direct or close swine contact, there are no reports of direct or
close contact with swine prior to illness onset in either of these
cases. Laboratory testing at CDC has confirmed that both novel viruses
are susceptible to the antiviral medications oseltamivir (Tamiflu) and
zanamivir (Relenza).

West Virginia
– ————-
One case of human infection with a novel influenza virus was reported
by West Virginia and involves infection of a child with the novel
influenza A (H3N2) virus with genes from swine, human, and avian
lineages with the M gene from the 2009 H1N1 virus that was first
identified in August 2011. Ten prior human infections with this virus
in 4 other states have been confirmed. These occurred in Indiana (2),
Pennsylvania (3), Maine (2), and Iowa (3).

These novel influenza A (H3N2) viruses are substantially different
from currently circulating seasonal (human) influenza A (H3N2)
viruses, but are distantly related to human influenza viruses that
circulated among people in the 1990s. For that reason, some adults may
have some residual immunity against this virus. This might help
explain why 10 of the 11 cases that have been detected have occurred
in children.

Most human infections with viruses that circulate in swine (but not
humans) have been associated with swine exposure, but limited
human-to-human transmission associated with these viruses is thought
to have occurred as well, most recently in Iowa. While an
investigation is ongoing in West Virginia, no direct or indirect
contact with swine has been reported, implying that limited
human-to-human transmission of this virus may have occurred again.

No ongoing community transmission of this virus has been detected in
the United States. However, CDC is taking this situation very
seriously. Surveillance surrounding reported cases is being further
enhanced and, as a precaution, a vaccine virus has been developed and
provided to manufacturers for them to begin vaccine production should
that become necessary.

Minnesota
– ———
The other case of novel influenza A virus infection was reported by
Minnesota, and is associated with a different influenza virus; an
influenza A (H1N2) virus that circulates in swine  in the United
States, but does not normally infect or cause illness in humans. This
case also was in a child. This is only the second case of human
infection with this novel influenza A (H1N2) virus reported to CDC
since novel influenza virus infections became nationally notifiable in
2007. The first such case was identified in Michigan in 2007. By some
characteristics, this H1N2 virus is close to human influenza A (H1N1)
viruses called “A/New Caledonia /20/99-like”, which circulated and
caused illness among people as recently as 2007. As a result, people
who were exposed to A/New Caledonia/20/99-like viruses may have some
existing immune protection against the virus detected in Minnesota.
Again, no direct or indirect contact with swine has been reported with
this case, implying that limited human-to-human transmission may have
occurred in this instance as well.

Detection of swine influenza infections in humans
– ————————————————-
Human infections with novel influenza A viruses normally found in
swine are rare events. Recently, however, the frequency of such
detections has increased. This could be occurring for a number of
reasons, including one or more of the following factors:
Firstly, laboratory methods for testing for these viruses in the
United States were improved following the 2009 H1N1 pandemic. These
improvements may be resulting in viruses being identified now that
would have gone undetected previously.
Secondly, this could be due to increased surveillance in the United
States for influenza at this time of year. CDC has requested that
states analyze, and then send, their first influenza virus specimens
of the season for seasonal influenza surveillance purposes. This
practice, coupled with very low levels of seasonal flu activity at
this time, could mean that sporadic novel influenza infections are
more likely to be tested.
Thirdly, it is possible that the increased frequency of detection of
novel influenza viruses with swine origins identified by CDC
represents a true increase in the number of such cases, possibly
occurring from exposure to infected swine or through subsequent,
limited human-to-human transmission.

The novel influenza A (H1N2) virus identified in Minnesota is known to
circulate in US swine herds. While the prevalence of the novel
influenza A H3N2 virus with the 2009 H1N1 M gene in swine is unknown,
the virus has been detected in US swine through the United States
Department of Agriculture’s swine influenza surveillance program.

In response to recent human infections with novel influenza viruses,
CDC would like to convey the following information:

* CDC recommends an annual seasonal flu vaccine to protect against
seasonal influenza viruses; however, a seasonal flu vaccine is
unlikely to protect against flu viruses that normally circulate in
swine.
* There are two FDA–cleared drugs that are expected to be effective
in treating illness associated with these viruses. The antiviral drugs
oseltamivir and zanamivir -– which are used to treat infection with
human seasonal influenza viruses –- also have shown activity against
influenza viruses from swine. (For more information about influenza
antiviral medications, please see
<www.cdc.gov/flu/antivirals/whatyoushould.htm>)
* Influenza has not been shown to be transmissible to people through
eating properly handled and prepared pork (pig meat) or other products
derived from pigs. For more information about the proper handling and
preparation of pork, visit the USDA website fact sheet “Fresh Pork
From Farm to Table”.

At this time, CDC recommends the following:
* People who experience flu symptoms following direct or close contact
with swine and who require medical attention (see below) should
mention this exposure to their doctor or health care provider. (A list
of flu symptoms is available at
<www.cdc.gov/flu/about/disease/symptoms.htm>.)
* For people who have NOT had exposure to swine and develop ILI
(influenza-like illness), CDC’s recommendations for seeking
treatment are the same as they are for seasonal influenza.
* If you have symptoms of flu and are very sick or worried about your
illness contact your health care provider.
* Certain people are at greater risk of serious flu-related
complications (including young children, elderly people pregnant women
and people with certain long-term medical conditions) and this is true
both for seasonal flu and novel flu virus infections. (For a full list
of people at higher risk of flu related complications, see
<www.cdc.gov/flu/about/disease/high_risk.htm>).
* If these people develop ILI, it’s best for them to contact their
doctor. (The majority of recent novel influenza A (H3N2) cases have
been in children.)
* Your doctor may prescribe antiviral drugs that can treat the flu.
These drugs work better for treatment the sooner they are started.

More information about swine influenza and links to all previous
reports related cases of novel influenza A (H3N2) viruses infections
are available on the CDC swine influenza website at
<www.cdc.gov/flu/swineflu/index.htm>.

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Fit or Fat: The Benefits of Exercise

Tuesday, December 6, 2011 // Uncategorized

Sometimes we set ourselves up for failure because our goals are higher than we can easily achieve.  We may not be able to lose weight, but it is still worth making the effort if we exercise. Here is yet another study showing the benefits of exercise.  Even if exercise results in no weight loss, those who exercise have a lower mortality at the same Body Mass Index that those who do not.

  • Original Articles
    • Epidemiology and Prevention

Long-Term Effects of Changes in Cardiorespiratory Fitness and Body Mass Index on All-Cause and Cardiovascular Disease Mortality in Men

The Aerobics Center Longitudinal Study

  1. Duck-chul Lee, PhD;
  2. Xuemei Sui, MD, MPH;
  3. Enrique G. Artero, PhD;
  4. I-Min Lee, MBBS, MPH, ScD;
  5. Timothy S. Church, MD, PhD;
  6. Paul A. McAuley, PhD;
  7. Fatima C. Stanford, MD, MPH;
  8. Harold W. Kohl III, PhD, MSPH;
  9. Steven N. Blair, PED

+ Author Affiliations


  1. From the Departments of Exercise Science (D.C.L., X.S., E.G.A., S.N.B.) and Epidemiology/Biostatistics (S.N.B.), Arnold School of Public Health, University of South Carolina, Columbia, South Carolina; Department of Medical Physiology, School of Medicine, University of Granada, Granada, Spain (E.G.A.): Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, and Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts (I.M.L.); Department of Preventive Medicine Research, Pennington Biomedical Research Center, Baton Rouge, Louisianna (T.S.C.); Department of Human Performance and Sport Sciences, Winston-Salem State University, Winston-Salem, North Carolina (P.A.M.); Departments of Internal Medicine and Pediatrics, University of South Carolina School of Medicine, and Palmetto Health Richland Hospital, Columbia, South Carolina (F.C.S.); Division of Epidemiology and Disease Control, University of Texas Health Science Center–Houston, School of Public Health, Michael & Susan Dell Center for Advancement of Healthy Living and Department of Kinesiology and Health Education, University of Texas at Austin, Austin, Texas (H.W.K.).
  1. Correspondence to Duck-chul Lee, PhD, 921 Assembly Street, Columbia, SC 29208. E-mail [email protected]

Abstract

Background—The combined associations of changes in cardiorespiratory fitness and body mass index (BMI) with mortality remain controversial and uncertain.

Methods and Results—We examined the independent and combined associations of changes in fitness and BMI with all-cause and cardiovascular disease (CVD) mortality in 14 345 men (mean age 44 years) with at least 2 medical examinations. Fitness, in metabolic equivalents (METs), was estimated from a maximal treadmill test. BMI was calculated using measured weight and height. Changes in fitness and BMI between the baseline and last examinations over 6.3 years were classified into loss, stable, or gain groups. During 11.4 years of follow-up after the last examination, 914 all-cause and 300 CVD deaths occurred. The hazard ratios (95% confidence intervals) of all-cause and CVD mortality were 0.70 (0.59–0.83) and 0.73 (0.54–0.98) for stable fitness, and 0.61 (0.51–0.73) and 0.58 (0.42–0.80) for fitness gain, respectively, compared with fitness loss in multivariable analyses including BMI change. Every 1-MET improvement was associated with 15% and 19% lower risk of all-cause and CVD mortality, respectively. BMI change was not associated with all-cause or CVD mortality after adjusting for possible confounders and fitness change. In the combined analyses, men who lost fitness had higher all-cause and CVD mortality risks regardless of BMI change.

Conclusions—Maintaining or improving fitness is associated with a lower risk of all-cause and CVD mortality in men. Preventing age-associated fitness loss is important for longevity regardless of BMI change.

Remember during the holiday season that whatever you do helps to maintain your fitness.  Maybe you can’t do what you normally do, but any exercise that you do helps.  Just do it.

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