Archive for January, 2012

High Value Testing

Wednesday, January 25, 2012 // Uncategorized

The Congressional Budget Office has estimated that up to 5% of the nation’s gross national product is spent on tests and procedures that do not improve patient outcomes.  Tests are necessary in the diagnosis and treatment of many diseases, but tests can beget more tests.  Sometimes tests can lead to other tests which may have side effects.  An example is a chest x ray which is ordered before surgery that shows a small nodule.  If there is not an old chest x ray to compare it with, sometimes the only way to prove that a nodule isn’t something serious, like cancer, is to biopsy it.

Biopsies can have complications, like bleeding or a collapsed lung which requires another surgical procedure to correct. A patient  may have a serious complication for something that never would have caused them a problem.The following table is a list of questions from an editorial by Christine Laine, MD, MPH, Editor in Chiefof  the Annals of Internal Medicine in the January 17th edition  which she recommends physicians should ask prior to ordering a test.

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Sex and Heart Disease

Sunday, January 22, 2012 // Uncategorized

It is said that the two most frequent uses of the internet are for pornography and medical information.  How great to be able to combine  the two.  Not really. This has to do with the American Heart Associations latest guidleines on sex and heart disease published in Circulation.

AHA: Sexual Activity Safe for Most People with Cardiovascular Disease
Sexual activity is associated with “reasonable” risk in patients with cardiovascular disease (e.g., coronary artery disease, valvular disease, heart failure) who are found to have a low likelihood for CV complications, according to a scientific statement from the American Heart Association, published in Circulation.
Among the other recommendations:
Sexual activity is not advised for patients with severe heart disease until their condition has stabilized.
Cardiac rehabilitation and exercise can lower the risk for complications from sexual activity in patients with CVD.
PDE5 inhibitors (e.g., sildenafil) are useful for treating erectile dysfunction in patients with stable CVD; they should not be given to patients taking nitrates.
The statement also notes that sexual activity with one’s usual partner is roughly equivalent to mild or moderate physical activity at 3 to 5 metabolic equivalents (METs).

What are the risks of sudden death while having sex?  Actually it is quite uncommon.  Here is an interesting tidbit from the Circulation article.

In an autopsy report of 5559 instances of sudden death, 34(0.6%) reportedly occurred during sexual intercourse. Two other autopsystudies reported similarly low rates (0.6%–1.7%) of sudden death related to sexual activity.Of thesubjects who died during coitus, 82% to 93% were men, andthe majority (75%) were having extramarital sexual activity,in most cases with a younger partner in an unfamiliar setting andor after excessive food and alcohol consumption. Theincrease in absolute risk of sudden death associated with 1hour of additional sexual activity per week is estimated to be less than1 per 10 000 person-years.

You can determine your own moral from those numbers.



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Don’t Inhale; Mixed News on Tobacco and Pot

Thursday, January 12, 2012 // Uncategorized

 I was surprised by this article in the New York Times about a study on nicotine replacement therapy.  I never thought that these nicotine replacements led to long term smoking cessation, but I thought they were useful in certain patients in the short term.  This article seems to support that idea.

 Nicotine Gum and Skin Patch Face New Doubt

Published: January 9, 2012


       gum and patches that millions of smokers use to help kick their habit have no lasting benefit and may backfire in some cases, according to the most rigorous long-term study to date of so-called nicotine replacement therapy.


Chris Goodney/Bloomberg News



The study, published Monday in the journal Tobacco Control, included nearly 800 people trying to quit smoking over a period of several years, and is likely to inflame a long-running debate about the value of nicotine alternatives.

In medical studies, the products have proved effective, making it easier for people to quit, at least in the short term. Those earlier, more encouraging findings were the basis for federal guidelines that recommended the products for smoking cessation.

But in surveys, smokers who have used the over-the-counter products, either as part of a program or on their own, have reported little benefit. The new study followed one group of smokers to see whether nicotine replacement affected their odds of kicking the habit over time. It did not, even if they also received counseling with the nicotine replacement.

The market for nicotine replacement products has taken off in recent years, rising to more than $800 million annually in 2007 from $129 million in 1991. The products were approved for over-the-counter sale in 1997, and many state Medicaid programs cover at least one of them. 

“We were hoping for a very different story,” said Dr. Gregory N. Connolly, director of Harvard’s Center for Global Tobacco Control and a co-author of the study. “I ran a treatment program for years, and we invested” millions in treatment services.

Doctors who treat smokers said that the study findings were not unexpected, given the haphazard way many smokers used the products. “Patient compliance is a very big issue,” said Dr. Richard Hurt, director of the Nicotine Dependence Center at the Mayo Clinic, who was not involved in the study.

Dr. Hurt said products like nicotine gum and patches “are absolutely essential, but we use them in combinations and doses that match treatment to what the individual patient needs,” unlike smokers who are self-treating.

The products have been controversial since at least 2002, when researchers at the University of California, San Diego, reported from a large survey that they appeared to offer no benefit. The study did not follow people over time. A government-appointed panel that included nicotine replacement as part of federal guidelines for treatment also came under fire, because panel members had gotten payments from the product manufacturers.

“Some studies have questioned these treatments, but the bulk of clinical trials have unequivocally endorsed them,” said Dr. Michael Fiore, director of the University of Wisconsin’s Center for Tobacco Research and Intervention and the chairman of the panel that wrote the guidelines. Dr. Fiore, who has reported receiving payments from drug makers, said that “there are millions of smokers out there desperate to quit, and it would be a tragedy if they felt, because of one study, that this option is ineffective.”

In the new study, conducted in Massachusetts, the researchers followed a representative sample of 1,916 adults, including 787 people who said at the start of the study that they had recently quit smoking. They interviewed the participants three times, about once every two years during the 2000s, asking the smokers and quitters about their use of gum, patches and other such products, their periods of not smoking and their relapses.

At each stage, about one-third of the people trying to quit had relapsed, the study found. The use of replacement products made no difference, whether they were taken for the recommended two-month period (they usually were not), or with the guidance of a cessation counselor.

One subgroup, heavy smokers (defined as those who had their first cigarette within a half-hour of waking up) who used replacement products without counseling, was twice as likely to relapse as heavy smokers who did not use them.

“Our study essentially shows that what happens in the real world is very different” from what happens in clinical trials, said Hillel R. Alpert of Harvard, a co-author with Dr. Connolly and Lois Biener of the University of Massachusetts, Boston.

The researchers argue that while nicotine replacement appears to help people quit, it is not enough to prevent relapse in the longer run. Motivation matters a lot; so does a person’s social environment, the amount of support from friends and family, and the rules enforced at the workplace. Media campaigns, increased tobacco taxes and tightening of smoking laws have all had an effect as well.


Marijuana smoke has toxic chemicals in it, but since people who smoke pot, smoke less than people who smoke tobacco, it may not cause the long term damage that tobacco smoke does.

Occasional Marijuana Use Not Associated with Impaired Lung Function


Patients may ask about a JAMA study suggesting that occasional marijuana use does not lead to reduced pulmonary function.




Some 5000 young adults completed questionnaires about tobacco and marijuana use and had physical exams periodically over 20 years. As expected, lung function (forced expiratory volume and forced vital capacity) was reduced among tobacco users, and it decreased with increasing levels of use. Marijuana use, however, was associated with improved lung function among participants who smoked up to 11–20 times in the previous month. With greater use, lung function appeared to level off and even decline.




The researchers conclude that occasional marijuana use might not reduce lung function, but note that their findings “suggest an accelerated decline in pulmonary function with heavy use and a resulting need for caution and moderation when marijuana use is considered.”


Here’s the abstract from the original article in JAMA.

Original Contribution
JAMA. 2012;307(2):173-181. doi: 10.1001/jama.2011.1961

Association Between Marijuana Exposure and Pulmonary Function Over 20 Years

  1. Mark J. Pletcher, MD, MPH;
  2. Eric Vittinghoff, PhD;
  3. Ravi Kalhan, MD, MS;
  4. Joshua Richman, MD, PhD;
  5. Monika Safford, MD;
  6. Stephen Sidney, MD, MPH;
  7. Feng Lin, MS;
  8. Stefan Kertesz, MD

[+] Author Affiliations

  1. Author Affiliations: Department of Epidemiology and Biostatistics (Drs Pletcher and Vittinghoff and Mr Lin) and Division of General Internal Medicine, Department of Medicine (Dr Pletcher), University of California, San Francisco; Asthma-COPD Program, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (Dr Kalhan); Department of Surgery (Dr Richman) and Division of Preventive Medicine (Drs Safford and Kertesz), University of Alabama at Birmingham; Center for Surgical, Medical and Acute Care Research and Transitions, Veterans Affairs Medical Center, Birmingham (Drs Richman and Kertesz); and Division of Research, Kaiser Permanente of Northern California, Oakland (Dr Sidney).


Context Marijuana smoke contains many of the same constituents as tobacco smoke, but whether it has similar adverse effects on pulmonary function is unclear.

Objective To analyze associations between marijuana (both current and lifetime exposure) and pulmonary function.

Design, Setting, and Participants The Coronary Artery Risk Development in Young Adults (CARDIA) study, a longitudinal study collecting repeated measurements of pulmonary function and smoking over 20 years (March 26, 1985-August 19, 2006) in a cohort of 5115 men and women in 4 US cities. Mixed linear modeling was used to account for individual age-based trajectories of pulmonary function and other covariates including tobacco use, which was analyzed in parallel as a positive control. Lifetime exposure to marijuana joints was expressed in joint-years, with 1 joint-year of exposure equivalent to smoking 365 joints or filled pipe bowls.

Main Outcome Measures Forced expiratory volume in the first second of expiration (FEV1) and forced vital capacity (FVC).

Results Marijuana exposure was nearly as common as tobacco exposure but was mostly light (median, 2-3 episodes per month). Tobacco exposure, both current and lifetime, was linearly associated with lower FEV1 and FVC. In contrast, the association between marijuana exposure and pulmonary function was nonlinear (P < .001): at low levels of exposure, FEV1 increased by 13 mL/joint-year (95% CI, 6.4 to 20; P < .001) and FVC by 20 mL/joint-year (95% CI, 12 to 27; P < .001), but at higher levels of exposure, these associations leveled or even reversed. The slope for FEV1 was −2.2 mL/joint-year (95% CI, −4.6 to 0.3; P = .08) at more than 10 joint-years and −3.2 mL per marijuana smoking episode/mo (95% CI, −5.8 to −0.6; P = .02) at more than 20 episodes/mo. With very heavy marijuana use, the net association with FEV1 was not significantly different from baseline, and the net association with FVC remained significantly greater than baseline (eg, at 20 joint-years, 76 mL [95% CI, 34 to 117]; P < .001).

Conclusion Occasional and low cumulative marijuana use was not associated with adverse effects on pulmonary function.

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World Flu Update

Sunday, January 8, 2012 // Uncategorized

Here’s the information from the World Health Organization on flu activity so far this year.  This is from Pro Med Digest and on line reporting service that sends daily (sometimes multiple times a day) reports on plant, animal and human disease activity around the world.  As a reminder, this is the compsosition of this year’s flu vaccine from the CDC’s website:

The Food and Drug Administration (FDA) recommended that the United State’s 2011-2012 seasonal influenza vaccine contain the following three vaccine viruses:

  • an A/California/7/2009 (H1N1)-like virus;
  • an A/Perth/16/2009 (H3N2)-like virus; and
  • a B/Brisbane/60/2008-like virus.

WHO Influenza Update number 150
– ——————————
– ————
– – Influenza activity in the temperate regions of the northern
hemisphere remains below seasonal threshold levels, though notable
increases in activity have been reported in some areas of Canada,
Europe (Spain and Turkey), northern Africa (Tunisia and Algeria), and
the Middle East (Iran). The persistence of the increased activity over
the last few weeks in these areas likely represents the start of the
influenza transmission season.

– – The viruses detected throughout the northern hemisphere temperate
zone have been predominantly of the A(H3N2) subtype. Only very small
numbers of influenza A(H1N1)pdm09 have been reported in recent weeks.

– – Countries in the tropical zone reported low levels of influenza
activity except for Costa Rica, which is primarily detecting influenza

– – Influenza activity in the temperate countries of the southern
hemisphere is at inter-seasonal levels, though Chile and Australia
both report persistent transmission of A(H3N2) with smaller numbers of
influenza type B in Australia.

Countries in the temperate zone of the northern hemisphere
– ————————————-
Influenza activity in the northern hemisphere temperate regions is
still below baseline, though increased respiratory disease activity
and influenza virus detections have been noted in some areas.

North America
– – North America circulation of influenza viruses (late March – end
December 2011 snapshot)

In Canada, the percent of positive influenza tests and consultation
rates for influenza-like illness (ILI) have persistently increased
since mid-December 2011. However, nationally, influenza activity
remained at inter-seasonal levels. Localized influenza activity was
reported in the region of British Columbia, and sporadic cases were
reported in 9 regions of 4 provinces (Alberta, British Columbia,
Ontario and Quebec). Three influenza outbreaks in long term care
facilities and 2 paediatric influenza hospitalisations were reported
in the last week. Of the 63 laboratory confirmed cases reported, 51
were influenza A(H3N2), 7 were unsubtyped influenza A, and 2 were
influenza type B. To date, this season [2011-2012], there have been 10
adult influenza hospitalisations, of which 6 were over 65 years of

In the United States of America, nationally, ILI consultations were
low (1.2 percent) and remained below the baseline level (2.4 percent),
and the percentage of samples positive for influenza remained below 2
percent; both have increased since mid-December 2011. Of the nearly
1000 virus detections reported since October 2011, 85 percent have
been influenza type A. Of the influenza A viruses that have been
subtyped, 84 percent were A(H3N2) and the remainder A(H1N1)pdm09. The
proportion of deaths due to pneumonia and influenza reported in the
122 cities sentinel surveillance system was low compared to previous

– – Western Europe circulation of influenza viruses (late March – end
December 2011 snapshot)

In Europe, influenza activity remains low, though respiratory disease
activity and influenza virus detections have started to increase in
some areas over a period of several weeks. ILI consultations and
admissions for severe acute respiratory infections (SARI) remain at
inter-seasonal levels overall. Of the 35 countries reporting on the
geographical distribution of influenza activity, 21 reported no
activity, one reported local activity (Italy), and 13 reported
sporadic activity in recent weeks. Spain and Turkey reported notable
increases in influenza virus detections among sentinel samples with
percentages of positive samples of 17 percent and 23 percent,
respectively. Influenza A(H3N2) was the most common virus detected. In
France, the consultation rate for acute respiratory infections
exceeded the seasonal baseline level; however, there was no
corresponding increase in ILI consultations or influenza virus
detections. 23 percent of European sentinel samples tested for
influenza in epidemiological week 51 were positive, a doubling from
the previous week. Influenza A(H3N2) was the most common virus
identified; 94 percent of 414 influenza A viruses characterized were
the A(H3N2) subtype.

Northern Africa and Eastern Mediterranean
The northern Africa and eastern Mediterranean regions have been
reporting increasing numbers of positive influenza specimens since
October 2011, particularly in Algeria, Tunisia and Iran. As in Europe,
influenza A(H3N2) was the predominant subtype detected.

Temperate countries of Asia
In northern China, influenza activity increased slightly, to 8.6
percent, since the previous week; influenza B virus is still the
predominant strain in China. Republic of Korea and Japan have both
reported small but slightly increased numbers of influenza positive
specimens in recent weeks, most of which were A(H3N2).

Countries in the tropical zone
– ————————-
Tropical countries of the Americas
No notable influenza transmission has been reported in the majority of
Caribbean and central American countries, with the exception of Costa
Rica, which has continued to report increasing numbers of influenza
A(H3N2) detections.

Sub-Saharan Africa
In sub-Saharan Africa, only sporadic detections or low level
transmission were reported. Transmission of influenza A(H3N2) in
Cameroon appears to be decreasing after peaking in mid-December 2011.
Kenya has reported continuous influenza transmission; however, the
number of positive specimens has been decreasing in the past 4 weeks
and is now at a very low level.

Tropical Asia
Overall, the influenza activity in tropical Asia remained low. Since
September 2011, India has continued to report low level influenza B
circulation. Following peaks in influenza activity in September 2011,
Lao People’s Democratic Republic, Cambodia and Viet Nam have reported
decreasing transmission, which has now returned to low levels. Other
countries in tropical Asia continue to report small numbers of both
A(H3N2) and influenza type B.

Countries in the temperate zone of the southern hemisphere
– ——————————-
– – Chile circulation of influenza viruses (snapshot) pdf, 390kb

– – Australia circulation of influenza viruses (snapshot) pdf, 395kb

In temperate countries of the southern hemisphere, influenza activity
is at inter-seasonal levels; however, Chile and Australia both report
low levels of persistent influenza A(H3N2), with much smaller numbers
of influenza type B also reported in Australia.

Source of data
– ————
The Global Influenza Programme monitors influenza activity worldwide
and publishes an update every 2 weeks. The updates are based on
available epidemiological and virological data sources, including
FluNet (reported by the Global Influenza Surveillance and Response
System) and influenza reports from WHO Regional Offices and Member
States. Completeness can vary among updates due to availability and
quality of data available at the time when the update is developed.

– ——-
Global circulation of influenza viruses (snapshot)

Northern hemisphere circulation of influenza virises (real time)

Southern hemisphere circulation of influenza viruses (real time)

Global Health Observatory — Map Gallery

– —
Communicated by:
ProMED-mail Rapporteur Marianne Hopp
In summary:  The flu activity has been low thus far this year and the strains reported are covered by the vaccine.  This is good news.

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Parsimonious Physicians?

Thursday, January 5, 2012 // Uncategorized

Parsimonious is a great word, but it sounds just a step above miserly.  This is an interesting article from NPR that discusses the responsibilities of  physicians not just to their patients, but to society.


 Should Doctors Be ‘Parsimonious’ About Health Care?


by Rob Stein


12:33 pm

January 3, 2012


A pensive doctor is surrounded by question marks and dollar signs.

George Peters/ 


A major medical group issued ethical guidelines on Monday that take the provocative position of urging doctors to consider cost-effectiveness when deciding how to treat their patients.

The American College of Physicians, the second-largest U.S. doctors’ group after the American Medical Association, included the recommendation in the latest version of its ethics manual, which provides guidance for some 132,000 internists nationwide.

“The cost of health care in the United States is twice that of any other industrialized countries and we are not providing care to as many people as they do in other places, and we don’t even have as good outcomes,” said Dr. Virginia Hood, president of the group. “So given that, we really have to look at ways of doing things better.”


As Heard On All Things Considered

heard on All Things Considered

January 2, 2012



One way to do things better is for individual doctors to think harder about the tests and treatments they give their patients, she said. More is not always better; in fact, it can often do more harm than good, she said.

“Every time you prescribe something for a patient or subject them to some kind of investigation there’s a risk of harm,” she said in a telephone interview. “So the concept of doing less is actually a really good concept, not a negative concept.”

As a result, the sixth edition of the manual, which is being published in the current issue of the Annals of Internal Medicine, includes the following passage:

“In making recommendations to patients, designing practice guidelines and formularies, and making decisions on medical benefits review boards, physicians considered judgments should reflect the best available evidence in the biomedical literature, including data on the cost-effectiveness of different clinical approaches.”

Now, Hood argues that considering cost-effectiveness would do far more than just help protect patients from costly and potentially dangerous tests and treatments they don’t really need:

“We also have to realize that if we don’t think about how resources are used in an overall sense then there won’t be enough health care dollars for our individual patients. So while concentrating on our individual patients and what they need we also to think on this bigger level both for their benefit and for the well-being of the community at large.”

Many health care policy experts say the guidelines are right on target. In an editorial accompanying the new guidelines, bioethicist Dr. Ezekiel Emanuel of the University of Pennsylvania calls the statement “truly remarkable” for taking on the sensitive issue so directly.

Emanuel has advised the Obama administration on health policy and has long advocated this way of thinking. It’s a position that provokes strong resistance from those worried about the federal government rationing health care.

And even those who support the concept in theory, are alarmed by some of the language used, especially this part:

“Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available.”

The word “parsimonious” strikes some as worrisome, almost Dickensian. “It’s going well beyond just giving advice to physicians about just being cognizant of the fact that we should use resources efficiently,” said Dr. Scott Gottlieb of the American Enterprise Institute. “I think that that’s generally accepted in medical practice right now.”

For Gottlieb, a parsimonious approach to medicine “really implies that care should be withheld. There’s no definition of parsimonious that I know of that doesn’t imply some kind of negative connotation in terms of being stingy about how you allocate something.”

For her part, Hood defended the wording, arguing the college simply means that efficient health care is good health care — both economically and medically. “Parsimonious is a good word in the sense that it means that you use only what’s necessary,” she said. “I don’t see a particular problems with that. Maybe it has some connotations where people think frugality or being parsimonious is the same as being mean or inadequate. But I don’t think that is the real meaning of that word.”

Even those who think doctors have to find ways to be more efficient, think the college’s position could fuel the already polarized struggle over costs. And that’s a fight that’s only likely to intensify in the coming year as the debate over the federal health care overhaul continues and the government pours millions of dollars into research aimed at providing doctors with better information about which tests and treatments work best.

“If you say say certain things will not be cost-effective, they’re not worth the money, well that’s rationing, particularly if some patients might benefit or simply some might desire it whether they benefit or not, whether it benefits them or not. So that’s where this all becomes a real viper’s pit,” said Daniel Callahan of the Hastings Center, a bioethics think tank.



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Exercises for Neck Pain

Tuesday, January 3, 2012 // Uncategorized

It is great when common problems can be treated with nonpharmacologic/nonsurgical treatments.  This summary from Journal Watch about an article in the current Annals of Internal Medicine deals with three different treatments for acute neck pain or neck pain that has been present for 2 to 12 weeks.

Spinal Manipulation, Home Exercise ‘Viable Treatment Options’ for Acute Neck Pain


Spinal manipulation is more effective than medication for improving acute neck pain, and home exercise might be as effective as spinal manipulation, according to an Annals of Internal Medicine study.




Some 270 adults with current, nonspecific neck pain lasting 2 to 12 weeks were randomized to 12 weeks of spinal manipulation (performed by chiropractors), medication (NSAIDs or acetaminophen, or both, as first-line treatment), or home exercise (following two instructional sessions). Patient-rated pain improved more with spinal manipulation than with medication both during treatment and at the 1-year follow-up. The researchers found “no important differences” between the spinal manipulation and exercise groups.




The researchers conclude that taken together with previous research, their findings suggest that spinal manipulation and home exercise with advice “both constitute viable treatment options for managing acute and subacute mechanical neck pain.”


Spinal manipulation has some potential side effects.  Injury to the arteries of the neck has been reported in patients who receive sudden thrusts to the neck.  For this reason, I have been reluctant to recommend these types of treatments to patients,

 Here is the Appendix of neck exercises.


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