Vol. 187 February 15, 2018 What is Love?

February 15, 2018

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It is a day after Valentine’s Day, a good time to ask, “what is love”?

Is it biochemical, just a roiling internal soup of our neurohormones? You can purchase potent messengers of love derived from that soup, sex pheromones, in various brands of solutions, lotions, and, shall we dare say, “potions” just a click or two away on the internet. Do they exist?

Or is it psychological, just a positive tilt in our balance scale of social experiences? An author on NPR just last week talked about her work on the definition of love, and she just rattled off an excellent one sentence definition: “Love is a collection of multiple positive moments shared with another.” Sorry, I can’t remember the name of her book. More about “multiple positive moments” leading to love later.

Even if we don’t know what love is, do we really know what it does?
Dr. Helen Reiss, Massachusetts General Hospital, lists five effects of love in her book The Empathy Effect.

1) “the honeymoon”
When you first fall in love “your head is in the clouds; you are walking on air.” Both effects are supported by a large outpouring of dopamine, the “really good feeling” hormone. Serotonin, the “mood regulating hormone”, also decreases at the same time which can explain both the ecstasy and the dramas of early love.

2) “the bonding”
As time passes the surge of dopamine subsides and there is an increasing level of oxytocin, the “bonding hormone”. Your neurochemical soup starts getting back into balance, and you approach a more steady state, one more conducive to the “long haul”.

3) “singleness anxiety”
The anxiety and loneliness of being single can lead to increased levels of norepinephrine, cortisol, and epinephrine, the “stress hormones”. Love lost is stress found.

4)  “togetherness medical benefits”
The diagnosis rate of advanced skin melanoma is lower in couples, and diseases with easy bruising are diagnosed sooner in people who are coupled, presumably because each person has another looking at their skin. (So saith Dr. Reiss) Also, each person in a couple may help break through the denial of the other about the need to see a doctor.

5) “Longer lives”
An increased disease protection for coupled  people is not just skin deep. Multiple studies have found that married people have less substance abuse, less depression, and lower blood pressure than single peers. A 2010 review of 148 studies of longevity revealed that increased longevity was associated with any “close social relationship”, not necessarily a romantic one. Family and friends do help.

Which gets me back to that “collection of positive moments shared with another” mentioned in the beginning. What about shared positive moments on social media? Does using Facebook increase your longevity? lower your blood pressure? Does it depend on your number of “friends” or on the number of hours spent on Facebook? What about any Match.com effect on melanoma diagnosis? Will questions like this provoke a new wave of important biosocial research, or will they merely spawn a blockbuster Sci Fi novel (film?) of a woman with 83 million Facebook friends who becomes President and lives cancer-free to 150?

After all, “love conquers all”.
Well, maybe not all of the time and in all of the places. Pakistan just this year outlawed St. Valentine’s Day as a threat of “increasing Westernization”.

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Vol. 186 February 1, 2018 Good News For Dieters, and Some Others Who Ingest

February 1, 2018

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“The only time to eat diet food is while you’re waiting for the steak to cook.”  — Julia Child

Pizza, even bad pizza, makes you feel good.
A recent study of 10 men in Finland (there’s the Finns again!) found evidence of high level of natural painkillers in their brains after eating a pizza. Their opioid receptors literally lit right up after the pizza! Even more surprising, the pizza did not have to be good to show that opioid receptor activity. If the same nutritional value was ingested in a “nutritional goo” form, the brains had even more opioid-like activity. So, the pleasurable feeling after eating pizza has nothing to do with how good it was. Speculations abound about a “full stomach feeling” or a “return of energy” as being the cause of the source of release of this endogenous opioid-like substance. (Journal of Neuroscience, November 2017)

Coffee can be part of a healthy diet.
A mega-review of over 200 studies of coffee consumption revealed that coffee consumption was associated with more benefit than harm, at all levels of consumption. Coffee contains more than 1000 bioactive compounds, including antioxidants, so this review was timely. The largest risk reduction of adverse health outcomes was found in those people who drank 3 to 4 daily cups of coffee (caffeinated OR decaffeinated!).  Death rates from any cause,  death rates from heart disease, and death rates from associated cardiovascular diseases were 15-19% lower in coffee drinkers. High coffee consumers had a 18% lower risk for cancer while lower consumers still had a 13% lower risk compared to non-coffee drinkers. The only adverse effects of coffee consumption were found in women: some higher risks for pregnancy loss, more preterm births, more low birth weight infants, and more bone fractures. The editor of the journal, anticipating our excitement at this news, counselled that “clinicians should not recommend coffee consumption on the basis of this review.”  And, oh yeah . . . this mega-review only included studies of black coffee. If you add sugar, milk, or any other ingredient to your coffee . . . “never mind”. (BMJ 2017)

Fecal transplants now come in pill form.
Selected cases of intractable diarrhea caused by recurrent infection with C. difficile (a bacteria that overgrows in the intestine after multiple courses of antibiotics) have been treated successfully by “transplanting” other people’s normal feces (material that contains normal symbiotic bacteria) into the patient’s intestines by infusing liquid fecal material either through a nasogastric tube or a colonoscope. In a study of 116 participants with recurrent, intractable diarrhea 96% were cured by the administration of the fecal material in a pill form. That is good news, but I hope that I won’t ever have to take that pill. (JAMA, Nov. 2017)

Low-dose aspirin does not raise your risk for intracranial bleeding.
A whole lot of people take daily low-dose aspirin (83 mg. – a baby aspirin) in the belief that it will reduce their risk of a fatal heart attack. The evidence actually shows that the preventative effect of low-dose aspirin is true only if you are trying to prevent your second heart attack; i.e.. the data supports its preventive effect in those people who already have clinical heart disease. Much of the general population, including me, is taking low dose aspirin in hope that it will work similarly for them. The only problem is that aspirin is an anti-thrombotic agent (it makes platelets “slippery” so that platelets don’t clump to start a clot). Such an effect raises a concern about spontaneous bleeding, particularly in the brain. A study of 400,000 people over 5 years in an established U.K. database showed that the incidence of brain hemorrhage was not significantly higher in those on the low-dose aspirin compared to those who took none. Remember also that if you have been taking low-dose aspirin for some time and decide to stop, your risk of spontaneous adverse clotting events may increase over the next 6-12 months. (Neurology, Nov. 2017)

Pasta is back!. . .  sort of.
An Italian study (no conflict of interest there I’m sure)  of 23,000 Italians revealed that the pasta lover had lower BMIs, the gold standard for definition of overweight. The researchers tout that pasta is not “just empty carbs”, but contains protein (6.7 grams per cup) and, if whole wheat pasta, it has iron, folic acid, and several B vitamins. The Italian study results are similar to a U.S. study of about 1,800 middle-aged adults, but there are a couple of caveats to consider. Italians eat much less pasta than we do in a meal because they consider it a first course, not the whole meal. The participants in the Italian study consumed an average of 3 oz. (86 grams) of pasta each meal. The study researchers did not name the “ideal amount” of pasta to eat per meal, but did note that those Italians who ate more pasta than the average tended to be obese. As we have said before, losing weight usually comes down to (no pun intended) taking in fewer calories rather than picking different kinds of calories to eat.


Vol. 185 January 15, 2018 New High Tech, Now and in the Future

January 15, 2018

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The start of a new year is a great time to look at some new medical technology and speculate a bit about how it might evolve.  This blog space is too limited to cover the inundation of new medical apps, so we will largely ignore them.

DIGITAL ADHERENCE MONITORING –
The title alone has an ominous ring, and that is not altogether an inappropriate feeling. A pharmaceutical company is testing a pill with a built-in sensory that can track AND REPORT ON whether or not the patient is taking a medication. The sensor is called an Ingestible Event Marker (IEM), which I think is only a slightly less ominous label. The IEM is activated when gastric contents reach it as the capsule dissolves in the patient’s stomach. The activated IEM sends a signal to a patch worn on the patients abdominal skin. The patch, in turn, alerts a cell phone app that reports the event to monitoring physicians. If the patient doesn’t take his medicine, of course, there is no electronic beep from the cell phone to the monitors. This gives the prescribing physician real-time data on the patient’s “adherence” to the prescription (used to be called “compliance”, but that was declared politically incorrect during the peak of concern with patient’s rights and autonomy). The same app can also track patient-reported activity, mood, and quality of rest. This package of new technology is called Digital Health Feedback system (DHFS), and, as you might guess by these tracking elements, this clinical test involved patients with a mental illness, schizophrenia to be exact. As one reviewer commented, “”It is ironic that this technology is being piloted with a drug used for paranoia.” (NEJM, Jan. 11, 2018, pg.101)

We are assured that the use of this technology is completely voluntary, and the patient can remove the reporting patch anytime they wish. A preliminary study of 28 patients using the IEM pill found that 27 completed the study, 24 of them thought that the technology would be useful to them, and 21 said they would like to receive reminders on their own cell phone if they forgot to take the medicine. (Ibid)

Despite the apparent compliance with this adherence pilot test, I can imagine how this might evolve in association with other new technology:
Alexa at 8:00 AM – “Good morning Herbert. Today’s weather is going to be unseasonably warm, you have a 10:00 AM appointment in your office, and be sure to take your high blood pressure pill after you eat breakfast.”
Alexa at 12:30 PM – “Keep up the good work Herb. You have only one scheduled appointment this afternoon, and I notice that you haven’t taken your blood pressure pill yet.”
Alexa at 5:30 PM – “Now Herb, remember that this pill should not be taken with alcohol. I know it must have been a hard day, but you don’t want to make it any harder on your body.”
Alexa at 8:30 PM – “Hey Herb! Not only have you not taken your pill, but I noticed that you skipped your regular visit to the gym today. Wha’sup? By the way, congratulations on your Weight Watchers dinner tonight.”
Alexa at 11:45 PM – “HEY STUPID! You forget to take your pill ALL day. Take your pill NOW, turn off Colbert, and go to sleep. Your family is counting on you, … not that I care, of course.”

VIRTUAL ENCOUNTERS –
Kaiser Permanente, the large California-based health system, reported that last year a majority (52% actually) of their 100 million patient encounters were “virtual visits”. (NEJM, Jan. 11, 2018, pg.104)  Virtual visits involve secure email and video engagements. Patient portals into medical offices, use of Skype, and teledermatology programs are familiar virtual tools. Telemedicine that allows monitoring of blood pressure, weight, blood glucose, and even EKG for home-bound patients with chronic disease are commonplace now. Future innovations could include cell apps that monitor the “total hours spent in high-allergen zones” for an asthma patient, or that deliver “intensive behavioral counseling” to people with obesity-related disease (“HERBERT! Step away from that refrigerator!”), or that make assurances that the patient’s near-empty automated pill dispenser (remotely monitored by the pharmacy, of course) would be filled soon by a forth coming home visit.

One author suggests that in the future “a face-to-face, in-person encounter would be reserved for the patients with the most health care needs – the 5% that account for 50% of costs. In-person encounters would become Option B”. (Ibid)  Obstacles to such progress could be patient fears of getting trapped in endless “phone menus”, lengthy voice message instructions, or numerous, sequential mouse clicking. Physicians might fear being marginalized, and, of course, no one is currently paying for these virtual encounters. A future evolution to mostly virtual visits would require a significant reorganization of and changes in reimbursement of medical care delivery. Kaiser Permanente’s virtual visit capacity is supported by the 25% of its annual $3.8 billion capital budget it spends on information technology.

Though I am tempted, I won’t go into what might happen if a future patient portal, an automatic pill dispenser, and Alexa signals got all mixed up together by mistake. Might a patient request for a 10:00 AM home visit on Tuesday result in 1000 AMbien pills being delivered to the patient’s home by AMazon on two days?

 


Vol. 184 January 1, 2018 To the Dark Side of EMR

January 2, 2018

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“… a fundamental barrier [to successful EMR implementation] that has not received due attention is the disconnect between health IT developers and users.” (1)

I was a solid advocate of electronic medical records (EMRs). Now I am a skeptic.

Primary care physicians are currently paying a big price, in terms of both time and money for the elusive promises of EMRs. As a quality reviewer of hospital medical records, an experienced office-based pediatrician, and a medical director working with an excellent medical staff, I believed that EMRs would really help us to improve the delivery of quality care. I happily jumped on the “evidenced-based medicine” bandwagon and believed that EMR data would help us. After three years of working with two different EMRs in a primary care practice, I have now “gone over to the dark side.” I have slowly realized that EMR “data” does not equate with “useful information” for primary care providers.

I have never belonged to the AMA, for me a “too-conservative” medical organization that I considered primarily a bastion of physician resistance to positive change. A definite sign of my conversion from EMR advocate to EMR skeptic is my agreement with a recent AMA statement by the Executive Vice-President and CEO of the AMA:

“Harnessing the power of health data is an enormous and important challenge, and one that should be led by physicians. The solution must be useful for physicians, and it must allow us to spend more time with our patients and deliver better care.”

Of course, there are all kinds of physicians in all kinds of practice settings, and “one size fits all” does not seem to be working for primary care EMR.

Use of EMR in our office is slowing us down, is decreasing the time we spend with patients and their families, is increasing the chances of provider communication gaps or slips, and has increased the frequency of “work arounds” for the delivery of quality care. “Work arounds” is a traditional quality improvement term that describes the methods that workers in any setting develop to skirt the system problems that hinder them from doing their best job. The presence of “work arounds” is one of the cardinal signs of a dysfunctional system. “Work arounds” often serve as the first target of any effort to analyze quality performance.

So why have I “gone over to the dark side”.
EMR has become way too complicated – There are too many screens requiring too many clicks, too many switches from scrolling wheel to cursor pointer, too many inconsistent navigation routes using tiny icons or miniscule, barely-noticed arrows. To see the basic clinical information I need before entering an exam room with our EMR ,  I need to review 2 or 3 computer screens, make 4 or 5 clicks with the mouse, and both scroll and/or drag with a cursor for the information that I use to be able to read quickly on two facing pages in the paper record.

In the quest for the versatility that is necessary to serve thousands of different physicians in hundreds of different settings, the award-winning EMR we use is awkward and time-consuming for us in primary care. It is driven by the need for reimbursement documentation in specialized (expensive) care settings. Workaround? – I read the paper encounter forms completed by my patients and my staff before I start the patient encounter. It is faster, sometimes more reliable (because there is no absent entry), and is more focussed on today’s encounter than those multiple computer screens which are trying so hard not to “miss” any data, no matter how irrelevant to today’s tasks.

EMRs have too many ways to record information from multiple sources – Valuable patient encounter information from nurses, social workers, and medical assistants can be hard to find in the mass of data. It usually requires purposeful clicking on tiny icons or miniscule arrows (again) on multiple screens. Boiler plate checklists tend to make every patient’s chart read the same. Workaround? – I know how to type. The actual, and helpful, differentiation between my patient encounters is almost always found in my “free text” note. But, not all providers in my office know how to or like to type. When I have to track down another provider to find out the information I need, there are now two of us not seeing patients.

Safeguarding patient privacy in an EMR is more complex. Sensitive results or comments are sometomes consciously avoided in the EMR or are deeply buried underneath a number of more clicks, scrolls, and screens. Workaround? – See above about physically tracking down another provider or more likely, that valuable information is not available in the medical record at the time that you need it. The route(s) of clinical information coming in from outside our office like lab results, X-ray readings, and specialists’ consultations are multiple, varied , and often obscure in our EMR. The vigilance required to NOT miss such reports is INCREASED, not decreased, in EMR. Workaround? – I ask the nurse, medical assistant, or front desk staff to track down the information by telephone or fax just like “in the old days.”

Correction of recorded errors like dates, or names, or even diagnosis can be tedious in the EMR.  A simple single line cross-out and rewrite did it in the paper record. The EMR requires multiple cursor clicks and several screens to do the same. The timing of the clicks, or more nearly correct, the sequence of clicks can be important for success. Workaround? – Sometimes I will delete a whole section of generic computer-speak in an EMR section because I can’t easily change one or two lines  (2 screen colors, at least 3 clicks, and a small check box way down at the bottom of the screen are often involvedin making an EMR correction).

The EMR has reduced the delegation of accepted clinical tasks. Renewing or initially writing common prescriptions ordered by me is not permitted to be done by the nurse practitioners or nurses on our EMR. Instead of a verbal request to a trusted professional, my time and attention is required on at least three computer screens, up to half a dozen clicks, and my entry of my unique password to do that. True, the prescription is sent electronically to the correct (usually) pharmacy, but the nurse or office staff used to do that quite quickly via fax, and it took less of my time. Work around? – Perhaps patient safety clearly trumps convenience here, so I have not spent much time thinking about a work around for this, but it does continue to disrupt a previously smooth work flow.

My computer keyboard is in one room, and I use three other rooms as exam rooms, To complete a note, look up a growth chart,  check results, answer an unexpected question from a parent, or order a medication I often do a far amount of time-consuming walking back and forth between rooms. Workaround? – Why not just get a tablet?, you ask. Well for some mysterious reasons neither of our EMRs support that functionality in our office. After several frustration attempts we know that the tablet works beautifully at IT headquarters, but  not in our office.

What benefits most from EMR in the office setting?
Reimbursement and research.
Clinically the only useful information to know about an ear infection is whether it is “left” or “right”. Our EMR requires a half dozen more adjectives before the diagnosis is “recorded”. It has no effect on reimbursement now (what we are paid for that office visit) ,as far as I know, and I can only hope that such minutiae won’t affect reimbursement in the future.
There are also half a dozen adjectives required to record the diagnosis of “nose bleed”, and I can only imagine that somewhere out there exists a researcher just waiting to write the definitive article on “recurrent, non-injury, chronic, episodic nosebleed” which happen more often on the “right” than the “left”.

Both these R&R benefits of EMRs are quite removed from improving actual clinical care. That is another reason for my move to “the dark side”, and this current blog that deviates from my founding pledge to NOT publish personal rants.

If you chose to dismiss this particular rant as “just another doctor complaining about his poor lot in life”, you should read a more scholarly short treatise on the same subject: “Accelerating Innovation in Health IT”,  New England Journal O f Medicine, 375:9, September 1, 2016, 815-7 (1).

 


Vol. 183 December 15, 2017 Santa’s Dirty Little Secrets

December 15, 2017

The recent deluge of headlines that have outed famous men for past discretion sparked in me a tiny bit of curiosity about the “most famous one of them all” … Santa Claus! Eagerly, and strangely expectant, I Googled “Santa’s Dirty Little Secrets”, only to find these :

 

 

 

 

 

 

 

 

However, my Google search of Santa did turn up several medical fun facts.

“The 10 dirtiest places in your home” according to a National Sanitation Foundation (NSF) study of 22 U.S. homes in 2011 are:
Top 10 with germ count
1. dish sponge –               321,629,869
2. toothbrush holder –        3,318,477
3. pet bowl –                            473,828
4. coffee reservoir –                 50,585
5. kitchen sink –                       31,905
6.pet toy –                                 29,365
7. faucet handle –                    28,068
8. counter top –                             559
9. bathroom door knob –             315
10. stove knobs –                           278

75% of kitchen sponges contained Salmonella, E.coli, and fecal matter compared to only 9% of bathroom faucet handles. The NSF recommended heating dampened kitchen sponges in the microwave for a minute. I already knew that. I watch “Mom” on TV. On one show mom, badgered by her daughter about a dirty kitchen sponge, put it in the microwave and walked away. The not-so-smart boyfriend then walked in and opened the microwave to put in his coffee cup,  paused, reached in, picked up the sponge, regarded it with great interest and remarked, “I always wondered how they made these things.”

Toilet seat, toilet handle, and bathroom light switch were way down in the germ quantity ranking. Personal items like cell phones, keys, wallet, computer keyboards, and bottoms of purses grew out germs, but relatively few, and mostly non-disease-causing germs like yeast and mold. Surprisingly, money had one of the lowest germ counts. The highest counts of disease-causing germs (E. coli) were in the kitchen, … no, not the bathroom.

Speaking of germs in the bathroom, I was recently told that hanging your toilet paper roll the “wrong way” could cause the spread of bad germs, specifically that toilet paper “hanging under and behind the roll encouraged the growth of Salmonella.” So, I Googled it. Googled what? “Toilet Paper Orientation”, of course, and where else but Wikipedia.

“Toilet paper when used with a toilet roll holder with a horizontal axle parallel to the floor and also parallel to the wall has two possible orientations: the toilet paper may hang over (in front of) or under (behind) the roll. The choice is largely a matter of personal preference, dictated by habit, (except in the case of the person who believes that under (behind) nurtures the growth of Salmonella (ed. note)). In surveys of US consumers and of bath and kitchen specialists, 60–70 percent of respondents prefer over. Some people hold strong opinions on the matter. Advice columnist Ann Landers said that the subject was the most responded to (15,000 letters in 1986) and controversial issue in her column’s history. Defenders of either position cite several advantages of each. Some writers have proposed connections to age, sex, or political philosophy, and survey evidence has shown a correlation with socioeconomic status.”

I found no mention of Salmonella, but I did find one reference concerning the spread of germs associated with toilet paper orientation.  It was a blog aimed at restaurant managers and their employees.

“Much of bacteria found in public restrooms is E. coli from human feces, a common source of food poisoning. E-coli is easily transferred from surfaces to your fingers and thence to anything that you eat with your hands. Which brings us to hanging toilet paper. The moment when a restroom user’s hands are most likely to carry bacteria is when they reach for toilet paper. If the toilet paper is hung “over”, their fingers only touch the toilet paper that they’ll be using, which will subsequently be flushed. However, if the toilet paper is hung “under” there’s a good chance their fingers will brush the wall as well, leaving a deposit. If so, every subsequent restroom user who reaches for toilet paper runs the risk of not only of picking up the bacteria that’s been deposited already, but also leaving more for the next user to pick up.”

Who knew? It’s amazing that any of us even survive a week out there in the world, or in our house.


Vol. 182 December 1, 2017 “This Is Not Your Father’s Heart Attack”

December 1, 2017

The remarkable facts, that the paroxysm, or indeed the disease itself, is excited more especially upon walking up hill, and after a meal; that thus excited, it is accompanied with a sensation, which threatens instant death if the motion is persisted in; and, that on stopping, the distress immediately abates, or altogether subsides; have . . . formed a constituent part of the character of Angina Pectoris. – “Remarks on Angina Pectoris” by John Warren, M.D., appeared in 1812 as the first article in the first issue of The New England Journal of Medicine and Surgery.


About this time of year in 1958 my father had a heart attack in Toronto.
He awoke in the morning with some chest pain that didn’t get better after a cold, brisk shower “to make it subside” (“De’Nile ain’t just a river in Egypt”).Then he walked up a flight of stairs to a physician’s office (more water down De’Nile), almost left the waiting room when the pain went away (ditto again), but immediately impressed the doctor with how pale and clammy he looked. He spent three (3) weeks on his back in a Toronto hospital bed with the diagnosis of “heart attack.:” He was allowed to return home to suburban New York City by train. I don’t remember why the train, but I think it had something to do with him traveling in a wheelchair (“activity still restricted”).

Things sure have changed. (NEJM 376:21 May 25, 2017)
The rate of hospitalization in the U.S.for a heart attack (acute myocardial infarction or AMI) has decreased by 5% PER YEAR since 1987. The rates of major complications have dramatically decreased during the same period. Deaths from acute MI have declined slowly since 1980, but 50% of the AMI deaths occur before the patient arrives at the hospital. Hence the push in recent years to teach CPR to everyone and distribute portable cardiac defibrillators/ automatic external defribillators (AED) as widely as possible.

There are now at least six types of heart attack.
The big divide is between those patients that have a specific change in their EKG, an elevation of the ST segment (STEMI) and those that do not (non-STEMI). STEMI implies significantly more heart damage and is treated more aggressively. Branching down off of these two big categories are 5 other distinct types of MI based on modern diagnostic modalities, both EKG findings and blood sample biomarkers, and therapies. I won’t bore you with all those details. Just remember that a “heart attack” is not just a “heart attack” anymore. It all depends…

There is distinctly different therapy for each type of AMI.
Today there is a lot more than “bedrest for three weeks.” Each AMI type has a best practice timeline which varies considerably, except that everyone arriving in the ER with chest pain gets an aspirin within 5 minutes (makes platelets “slippery” to reduce clotting of blood in small coronary arteries). After that:

  • you may be whipped into the cardiac cath lab within 90 minutes for percutaneous cardiac intervention (PCI – a catheter in a radial (wrist) artery) to stent your coronary artery(s);
  • or you may be given a stress test and be sent to the cardiac cath lab for a diagnostic catherization and then maybe scheduled for open heart surgery (CABG) that day or days/week later;
  • or you may be admitted to a CCU/ICU bed;
  • or you may be admitted to an “observation bed” or “step down unit” which have outcomes as good as a CCU or ICU.
  • or you could even be sent home.
    You will probably be anti-coagulated as well. Most admitted non-CABG patients stay in the hospital for no more than 3-4 days.

Some studies credit the declining death rate from cardiovascular disease to better prevention (Public health and primary care interventions). Others credit better, more timely diagnosis and treatment (scientific advances). Both are correct.

 

Decline of cardiovascular deaths due to scientific advances.
(NEJM 366:1, January 5, 2012)

Decline of cardiovascular deaths due to public health and primary care interventions.
(NEJM 366:13 March29,2012)

Numerous studies have shown that the biggest influence on your chance of having a heart attack is genetics; what you inherit from your parents. The good news is that if you have NOT picked your parents well, life style changes like no smoking, exercise, no obesity, and a healthy diet can reduce even the high risk for coronary disease by nearly 50%. (NEJM 375:24 December 15, 2016)

 


Vol. 181 November 15, 2017 Here’s Some More Good News …and Bad News

November 15, 2017

Do not believe in anything simply because you have heard it.
Do not believe in anything simply because it is spoken or rumored by many.
Do not believe in anything simply because it is found written in your religious books.
Do not believe in anything merely on the authority of your teachers and elders.
Do not believe in traditions because they have been handed down for many generations.

But after observation and analysis when you find out that anything agrees with reason and is conducive to the good and benefit of one and all, then accept it and live up to it.
-Buddha

THE GOOD NEWS is …
Neurosurgeons in one hospital  were able to double-book operations (operate on two patients at the same time) without increasing complications like infections and bleeding, and they had  same, good outcomes of those who didn’t double-book. The other good news is that seven separate studies of double-booked cases (all since the MGH dust-up caused by a whistle-blowing orthopedic surgeon) revealed no difference in complications compared to single cases.
THE BAD NEWS is …
The double-booked neurosurgical patients had 30 minutes longer of anesthesia and their incisions were open for 30 minutes longer (increased chance of contamination). The other bad news is that orthopedic surgeons who double-booked hip surgery have higher complications than those who didn’t. (JAMA Surgery. Nov. 15, 2017)

THE GOOD NEWS is …
Congress just passed the Elizabeth Warren (D-MA) co-sponsored 2016 bill that will allow people to obtain hearing aids (called PSAPs- “Personal Sound Amplification Products”) over the counter (OTC)without a prescription. These PSAPs will be much cheaper than the currently exorbitantly priced “professional hearing aids”, and will be just as good using upgraded technology.
THE BAD NEWS  is ...
You won’t be able to buy them for at least three years. That is how long the FDA will take to develop regulations (specifications) and approve their sale. In the meantime, some of my friends will continue to “not hear me”, and my post office box will continue to overflow with offers of “free hearing tests” from professional vendors of very expensive hearing aids. (Boston Globe November 12, 2017)

THE GOOD NEWS FOODS of  Thanksgiving are…
1. Turkey – Lower calories than a standing rib roast and a lot less sodium than spiral ham. The myth of tryptophan making us drowsy has been debunked several times.
2. Pumpkin – That’s “pure” pumpkin spice. No sugar. Pumpkin pie filling with 27 grams of sugar in a half-cup is a no-no.
3. Sweet potatoes – cooked in just a little olive oil only. Casseroles and canned variety are to be avoided.
4. Cranberries –  It is high fiber and has rich plant compounds to help you metabolize the sugar which they grudgingly admit you have to add to make it taste good.
5. Hot cocoa – Make your own, of course, with unsweetened cocoa, low-fat milk, and a teaspoon (a whole teaspoonful?!!) of sugar.
6. Shrimp cocktail – This is my favorite. I am so glad nutritionists suggest it over cheese and crackers. Forget about its cholesterol (dietary cholesterol has little impact on your blood level), but go easy, of course, on the high sodium cocktail sauce. (You knew the nutritionists had to ruin a good thing eventually).
THE BAD NEWS FOODS are …
1. Egg Nog – 224 calories and 20 grams of sugar per half-cup (Whoever drinks only half a cup?)
2. Coffee drinks made with peppermint flavor, 2% milk, and 13 teaspoons of sugar. (A holiday grande latte at Starbucks can contain as much sugar as 7 glazed Dunkin Donuts.)
3. Pecan pie – A surprise. Twice the calories of pumpkin pie!
4. Green bean casserole – Another surprise. The word “casserole” is the tip-off. A half cup of green beans has 20 calories. A half cup of the green bean casserole with creamy mushroom soup and crispy fried onions weighs in at 227 calories a half cup.
5. Cranberries – What? They were labeled “good” above. Yes, but their medical benefits (separate from their nutrition ones) have been debunked. (On Health, Consumer reports, December 2017)

THE GOOD NEWS is …
A daily dose of  a 83 mg.baby aspirin  reduces your chances of a cardiac event, either a repeat event  or even a primary cardiac event if you are at high risk.
THE BAD NEWS is …
If you stop taking that aspirin for any reason your chance for a cardiac event in the next year increases by 37%, … at least for 1 out of every 74 Swedes in this study. “This study provides strong evidence for continuing aspirin indefinitely…” (NEJM Journal Watch Cardiology, Nov. 2017)

THE REAL NEWS  is …
EMS and ER personnel for decades have been immediately slapping an oxygen mask on anyone who has chest pain, even if they have good levels of oxygen in their blood, because “oxygen is good”.
THE BAD NEWS is …
Since 1950 we have “known” that oxygen doesn’t really help. In 1976 a prospective, randomized study showed that the patients receiving oxygen had larger infarcts and a slight trend toward higher mortality than those who didn’t receive oxygen. “Notwithstanding the results of this trial, for the next 40 years, oxygen therapy continued to be administered routinely to patients with acute coronary symptoms even though their oxygen blood levels were normal.”  A current study of 6629 Swedes (what is it with all these studies of Swedes?) with chest pain and normal oxygen levels in their blood showed that those who received 100% oxygen rather than ambient air had no benefit from it. “It is clearly time for clinical practice to reflect this definitive evidence.” (NEJM September 28, 2017)

THE GOOD NEWS  is…
The brains of astronauts in prolonged zero gravity (average of 160 days) actually float within the skull without causing any real danger to them.
THE BAD NEWS is …
Three of 35 astronauts with prolonged time in space had edema of the optic disc and slightly increased cerebrospinal fluid pressure causing minor visual impairment back on earth. Actually, this was good news for the researchers because it gave them a publishable article justifying expensive use of MRIs, including cine MRIs, to define a new syndrome, VIIP (“visual impairment and intracranial pressure syndrome”. (NEJM November 2, 2017)

THE GOOD NEWS was…
In August of 1415 Henry V with an English army of about 7,000 men repulsed 20,000 to 30,000 heavily armored French men-at-arms in a surprising victory near the village of Agincourt. Celebrated by Shakespeare as a triumph of English rhetoric, historians point to the self-defeating crush of the French charge as the cause.
THE BAD NEWS is …
Exercise physiologists recently dressed volunteers in 15th century armor weighing from 30 to 50 kilograms and ran them on a treadmill while monitoring their oxygen consumption. The armor caused at least a doubling of the volunteers’ metabolic requirements. The same amount of weight worn in a backpack only caused a 70% increase. The weight of the armor distributed over the French arms, hands, legs, feet, and head as the men-at-arms slogged through 300 yards of deep mud to reach the English probably helped make it the “final charge” for many of them. (Scientific American October 2011)


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