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Old April 27th, 2002, 20:27
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April 21 - April 27, 2002

Primary Care Pearls for April 21 - April 27, 2002

Saturday, April 27, 2002

Philadelphia Hospital Stops Delivering Babies Due to Liability Insurance Costs.
In part due to Philadelphia's Methodist Hospital's decision to stop delivering babies due to liability insurance costs doubling, legislation was introduced in the US House of Representatives to reform the medical tort system. Comment: see an earlier pearl noting that tort reform is DOA in the US Senate under the current Democratic leadership. [ article ] posted by Internet Medical Journal 03:53 GMT medjournal.com

Tort Reform Would Save Billions of Dollars, Improve Care.
Phillip K. Howard, head of the bipartisan nonprofit policy coalition called Common Good, recently stated that tort reform would save approximately $50 billion US dollars. This is enough to pay for 25 million Americans to get health insurance. The savings would come primarily by reducing defensive medicine- the practice of prescribing unnecessary medicines and unnecessary referrals out of fear of malpractice lawsuits. He supports his views in part by quoting a recent Harris poll of doctors. This poll found that 96% of doctors believe that most malpractice claims are not brought because of medical error. Furthermore, 83% said they do not trust the courts to reach a fair result. Also, 73% reported seeing other doctors protect themselves by over-prescribing and over-referring. The poll not only found that doctors regard the current malpractice climate as harassment, it also found that the majority of Americans are concerned that the medical liability situation limits access to medical care. Comment: research has found no correlation between malpractice lawsuits and quality of care. Actually, the opposite has been shown to be true. The most talented, best trained physicians at the peak of their career (generally in their 50's) have been shown to be sued more often than other doctors. Why? Because they are the best doctors, they tend to see the sickest patients. Also, they tend to have large practices. Since lawsuits are correlated with bad outcomes (an unavoidable part of life) and not bad medical care, these top physicians are sued more often. Furthermore, the outcome of trials has not been correlated with poor medical care. Tort reform would improve medical care by improving access and decreasing the practice of defensive medicine. Isn't it about time that our Democratic politicians bring some balance back, and enact tort reform? [ article ] posted by Internet Medical Journal 03:19 GMT medjournal.com

First Three Months of 2002 Warmest Ever Recorded.
The first three months of 2002 were the warmest ever since records began in 1860, and most likely the warmest for at least the previous 1000 years. [ article ] posted by Internet Medical Journal 02:52 GMT medjournal.com

Switch From Aspirin to COX-2 Inhibitors May Hurt Your Heart.
Switching from daily aspirin to one of the newer COX-2 arthritis medications may result in cardiac complications. Aspirin suppresses prostaglandin and thromboxane, whereas COX-2 inhibitors only inhibit prostaglandin. Thromboxane can have harmful effects upon the heart. [ article ] posted by Internet Medical Journal 02:26 GMT medjournal.com

Terrorists Target Doctors in Pakistan.
The author of this article, an assistant professor of medicine at Aga Khan University in Pakistan, describes the terror associated with practicing medicine in Pakistan. Currently, doctors are being targeted by drive-by shootings. An eye opening testiment to the dedication of physicians worldwide. [ article ] posted by Internet Medical Journal 01:59 GMT medjournal.com

Insurance Company Tells Patients to get Medications Over the Internet.
A German health insurance company recently announced that patients should buy their drugs on the Internet to save money. Furthermore, a roundtable of the German Health Service came down in favor of the Internet trade of pharmaceutical drugs. Comment: While delivery of over-the-counter medications may be reasonable, prescribing medications via an online, faceless consultation with a physician is going too far. The online pharmacy at issue is DocMorris.Com [ article ] posted by Internet Medical Journal 01:43 GMT medjournal.com

Most Heart Attack Victims Treated in Hospitals Without Angiography.
This study of 451 heart attack patients in Massachusetts and Maryland found that primary angioplasty was slightly more effective than thrombolytics (mortality 6.2% in the angioplasty group vs. 7.1% in the thrombolytic group). Currently 2/3rds of patients with an acute heart attack in the United States are treated in hospitals that do not have coronary angioplasty available. [ article ] posted by Internet Medical Journal 01:32 GMT medjournal.com

Male Circumcision Associated With Lower Cervical Cancer Rates.
This study of 1913 couples found that the risk of cervical cancer was less when the male partner was circumcised. [ article ] posted by Internet Medical Journal 01:22 GMT medjournal.com

Nuclear Medicine Breath Test as Effective as Endoscopy in Diagnosis of H.Pylori.
In this study of 708 patients found that the C-14 non-invasive breath test was as effective as endoscopy in diagnosing H.Pylori infection. Comment: perhaps this will convince insurance companies to cover the less expensive, less invasive breath test. We used the breath test in our clinic a few years ago, but due to a complete lack of reimbursement from the insurance companies, we were unable to continue purchasing the kits and performing the test. [ article ] posted by Internet Medical Journal 01:18 GMT medjournal.com

Household Composition a Risk Factor for Abuse.
This article in the journal Pediatrics found that children in homes with an unrelated adult (usually the biological mother and a boyfriend) were more likely to be abused as compared with children living with one biological parent and no other adult, or with both biological parents. [ article ] posted by Internet Medical Journal 00:58 GMT medjournal.com


Thursday, April 25, 2002

Deadly Virus in Greece Closes All Educational Institutions.
All Greek educational institutions were closed in an attempt to prevent the spread of an unidentified, deadly virus that has killed three people and infected 32 people. Comment: this is an excellent strategy. In the case of an unknown or incurable outbreak of an infectious disease, quarantine is highly effective. [ article ] posted by Internet Medical Journal 23:39 GMT medjournal.com

Tort Reform Unlikely Due to Senate Democrats.
Experts say that a federal tort reform bill introduced in the US House is unlikely to become law due to Democratic control of the US Senate. The bill would help bring obstetrical care to many poor, rural areas where physicians are currently unable to practice due to malpractice insurance costs being higher than their income. Comment: why are the Democrats always against measures that would bring balance back to our out-of-control legal system? Perhaps it's because the Association of Trial Lawyers of America contributes a lot more to the Democratice party than the people living in poor, rural areas do. It would be nice to get the trial lawyers to take this problem seriously, and help us fix this problem. [ article ] posted by Internet Medical Journal 23:30 GMT medjournal.com

Whole Grain Oat Cereal Reduced Blood Pressure and Cholesterol.
Daily consumption of whole oat cereal found that it not only decreased total cholesterol by an average of 15% in 12 weeks, it also reduced the need for blood pressure medication. [ article ] posted by Internet Medical Journal 23:12 GMT medjournal.com

Diluted Smallpox Vaccine Effective.
This study of 680 adults who had not been previously immunized were innoculated with 3 different strengths of the smallpox vaccine: regular, a 1:5 dilution, and a 1:10 dilution. All strengths were found to be equally effective in vesicle formation, the surrogate marker used by the researchers to indicate successful vaccination. [ NEJM ] posted by Internet Medical Journal 00:48 GMT medjournal.com

Dental Health Problems in China.
It is estimated that almost half a billion people in China never brush their teeth. [ article ] posted by Internet Medical Journal 00:39 GMT medjournal.com

Good News for Women?.
This study of the medication Cabergolin found that the young healthy males who took it were able to have several orgasms within a few minutes. Normally, men this age require about 20 minutes between love making. Comment: see the previous pearl on "Disease Mongering: Sex." Do men this age really need a medication that gives them more orgasms? [ article ] posted by Internet Medical Journal 00:37 GMT medjournal.com

One in Five Women Forget to Take Birth Control Pill at Least Twice a Month.
British doctors are being urged to discuss more contraceptive options with women other than just the pill due to the frequent non-compliance with taking the medication correctly. This survey of over 600 young women found that one in five women forget to take their birth control pill at least twice monthly. [ article ] posted by Internet Medical Journal 00:31 GMT medjournal.com

Nontraditional Roles for Men and Women Linked to Premature Death.
This study of nearly 3700 participants over a 10 year period, and based on the Framingham data, found that men whose primary job was as a househusband had a 82% higher 10-year death rate as compared to men who worked outside of the home. Women with high job demands outside of the home suffered higher rates of heart disease compared to housewives. The researchers took into account known risk factors such as smoking, age, cholesterol, stress, and household responsibilities. Comment: the researchers hypothesize that men and women who go against traditional societal roles may have encountered greater stress leading to the health problems. This is an unusual study. I haven't come across anything like it previously. [ article ] posted by Internet Medical Journal 00:22 GMT medjournal.com


Wednesday, April 24, 2002

American Pain Society Lobbies Congress.
Last December, the American Pain Society (APS) lobbied congress to not infringe upon the ability of physicians to treat pain. The appeal was made as the FDA and DEA are considering new regulations to limit access to pain medications (to help control diversion and abuse). According the the APS President Michael Ashburn, MD, "Pain is one of the most common reasons people consult a physician, yet it frequently is inadequately treated, leading to enormous social cost in the form of needless suffering, lost productivity and excessive health care expenditures." He also said that "No legislation or regulation can take into account all the nuances of particular clinical situations as they evolve. Only a physician, together with his or her patient in the context of the doctor-patient relationship, has the information necessary to decide what approaches, structure and therapeutic tools are appropriate for the management of pain in a particular situation." Comment: Amen! It takes a lot of education to become a licensed, board-certified physician. Yet bureaucrats with less than half the education frequently want to tell physicians how to practice medicine. Yes, regulations and standards for physicians are necessary, but balance is needed. Currently there is no balance. Over-regulation, bureaucratic paper-work, and demonizing of doctors by the government (except when they are sick) is the norm. A more reasonable balance is needed in order to improve the quality of our healthcare system. We need have lawyers and lawmakers stop practicing medicine. [ article ] posted by Internet Medical Journal 14:42 GMT medjournal.com

American Pain Society Releases Guidelines for Arthritis Pain Management.
Guidelines on managing pain in arthritis patients have been issued by the American Pain Society. In brief, the guidelines call for the initial use of acetaminophen for mild to moderate pain, then COX-2 inhibitors, then opiods. It is notable that the guidelines call for the use of opiod analgesics for patients in certain arthritis patients. Lifestyle recommendations, such as staying active and maintaining a normal body mass are also emphasized. Comment: these are helpful guidelines. [ article ] posted by Internet Medical Journal 14:26 GMT medjournal.com

Ban on Antibiotics in Animal Feed Reduces Antibiotic Resistance in Humans.
Danish researchers have found that a ban on the indiscriminate use of antibiotics in livestock animal feed can lead to a substantial drop in antibiotic resistant bacteria in humans--- and not adversely affect the animals' health or growth. In the late 1990's, Denmarks livestock producers agreed to stop the routine use of antibiotics in livestock feed. This has reduced human bacterial disease. For example, in 1989-1990 more than 80% of the broiler chicken flocks were infected with Salmonella compared with only 2% to 3% in 2001. In the 1980's the incidence of salmonellosis (the human disease that can be caught from infected chicken eggs) per 100 000 population in Denmark was 30, compared with 3 per 100 000 in 2001. Good News: three large US companies -- Tyson Foods, Perdue Farms, and Foster Farms -- have phased out the practice of using antibiotics in animal feed. Comment: when I buy chicken, it is going to be from Tyson, Perdue, or Foster. [ article ] posted by Internet Medical Journal 14:18 GMT medjournal.com

Pap Smear Guidelines Updated.
This consensus statement updates recommendations on how to manage the patient with a pap smear showing atypical squamous cells of undetermined significance. [ JAMA. 2002;287:2120-2129 ] posted by Internet Medical Journal 14:05 GMT medjournal.com

Dietary Dairy Intake Linked to Cardiovascular Risk Reduction.
This study of 3000 adults aged 18 to 30 years old found that increased dietary intake was associated with a decreased risk of insulin resistance syndrome: the combination of obesity, dyslipidemia, and glucose intolerance. Comment: another study linking certain dietary patterns with improved health. This link, however, confuses the picture of what is a good diet. Diary products, such as butter, milk, and cheese, are all generally high in fat, and a diet high in fat has been linked to increased cardiovascular risk. My conclusion is that the saying "all things in moderation" is still valid today. The best book on a healthy diet I've come across recently is The 20/30 Fat and Fiber Diet Plan which makes a lot of sense to me (but it doesn't recommend a diet high in diary) [ JAMA. 2002;287:2081-2089 ] posted by Internet Medical Journal 13:56 GMT medjournal.com

Antibiotic Resistance in Animals Spreads to Humans.
Antibiotic resistance in animals appears to create similar antibiotic resistance in humans. Comment: no kidding! See previous pearls for my thoughts on this matter- in brief, a) livestock farmers use antibiotics freely because the antibiotics promote growth in the livestock (leading to increased profits), b) the USA is among the worst offenders in terms of antibiotic abuse by livestock farmers, and c) since antibiotics promote health and growth, why don't we reserve them for humans? Or do we put financial profits (of the livestock farmers) above public health? Physicians are being pressured to decrease antibiotic prescribing -- why isn't there a similar pressure on livestock farmers? [ take the poll ] [ article ] posted by Internet Medical Journal 03:25 GMT medjournal.com

Doctor Convicted of Manslaughter for Oxycontin Prescribing.
Officials from the Drug Enforcement Administration have stated that the prosecution of Dr. James Graves of Pace, Florida is part of a national crackdown on the abuse of prescription drugs. He was recently convicted of four counts of manslaughter, and faces up to 15 years on each of the counts. He also faces 30 years for racketeering. At least two other doctors are currently facing similar charges. Laura Nagel, head of diversion control for the DEA, reportedly has stated that this conviction is intended to send a strong message to physicians to be more cautious about prescribing narcotics. Comment: the specifics of this case are almost irrelevant. What is relevant is the statement from the DEA official that this is part of a nationwide crackdown (witch hunt ?). Who will face manslaughter charges next? Are honest, competent, board-certified physicians going to be caught in this crackdown? If you have chronic pain, be ready to suffer more- fewer doctors are going to help you control your chronic pain. [ Physicians Financial News 30-April-2002 ] posted by Internet Medical Journal 02:00 GMT medjournal.com


Tuesday, April 23, 2002

Government Regulations Too Complex Even for the Experts.
The government frequently criticizes and accuses doctors of committing fraud when they submit incorrect billing codes (CPT codes). The complex method established by the government to determine whether or not a doctor assigns the correct code is out-of-control, with some research showing doctors being accurate only 50 to 60% of the time. Now, it has been confirmed that even specialists certified to review CPT codes, with an average 10 years of experience, are as terribly inaccurate as well. The certified experts studied disagreed over 40% of the time on what the proper billing code should be. Comment: aren't you glad that your doctor has to spend so much time trying to learn crazy, confusing government regulations? We spend an inordinate amount of time trying to learn the government's nutty regulations, and when we are wrong, the government accuses us of fraud! Even the certified experts, whose full-time job is to assign proper CPT codes, have big problems following the regulations. How about simplifying things so doctors can spend more time with their patients, more time studying medicine instead of government regulations? What would you rather have your doctor read, the New England Journal of Medicine or the bureaucratic government's billing code regulations? These guidelines seem to be just as complex as IRS rules, and who really understands the IRS code? Very few of us. Fraud and waste are a big concern, but these findings suggest that the biggest waste is due to the government's overly bureaucratic, complex, idiotic, crazy over-regulation. Let's let doctors practice medicine, and not create undue (crazy) burdens that interfere with patient care. [ Family Practice News 15-Feb-2002 ] posted by Internet Medical Journal 23:18 GMT medjournal.com

Ibuprofen Blocks Aspirin Benefit.
Multiple daily doses of ibuprofen blocked the antiplatelet benefits of aspirin in this small study of 18 patients. Delayed release diclofenac and rofecoxib did not interfere with aspirin's antiplatelet effect. Comment: this study suggests that ibuprofen should not be used to treat osteoarthritis in patients using aspirin as a preventive agent for myocardial infarction. NEJM 2001;345(25):1809. posted by Internet Medical Journal 22:45 GMT medjournal.com

Family Physicians Lead the Way in Reducing Antiobiotic Prescriptions.
Based on data collected by the National Center for Health Statistics at the CDC, antibiotic prescribing for children fell by 31% during the 1990's. Comment: This is a positive development in the fight against antibiotic resistant bacteria. Family Practice News, 1-March-2002. posted by Internet Medical Journal 22:40 GMT medjournal.com

Glucosamine Helps Fight Osteoarthritis of the Knee.
In this retrospective analysis of two randomized, placebo controlled trials, women taking oral glucosamine did not experience any joint space narrowing over the three year study period. This compared to a 0.33 mm increase in joint space narrowing among those treated with placebo. Symptoms were also improved in the glucosamine group. (Dr. Carmelo Gonzalez-Rodriguez at the annual meeting of the North American Menopause Society, as reported in Family Practice News, 1-March-2002). posted by Internet Medical Journal 22:36 GMT medjournal.com

ACE Inhibitors Lower Overall Mortality in Diabetics.
This study of 572 diabetics found that the ace inhibitor captopril was more beneficial than beta-blockers or diuretics in the treatment of their hypertension. Those on captopril had not only a lower cardiovascular and stroke event rate, but also a lower overall mortality rate. Diabetes Care 2001;24:2091. posted by Internet Medical Journal 22:32 GMT medjournal.com

Antioxidants and Some Heart Medicines Don't Mix.
This study of 160 patients with known coronary artery disease found that antioxidants negated the benefit of a simvastatin-niacin treatment program. Those on antioxidants alone or antioxidants plus simvastatin-niacin had a similar cardiovascular event rate as did those on placebo. Those on the simvastatin-niacin regimen had greatly reduced event rates. Comment: this three year study strongly suggests that antioxidants are not helpful in preventing cardiovascular events in people with known coronary artery disease. Furthermore, it documents the tremendous benefits from established, mainstream medical therapy. Alternative medicine in this case was shown to be harmful. NEJM 2001;345:1583. posted by Internet Medical Journal 22:29 GMT medjournal.com

Topical Impotence Cream.
A topical cream used to treat impotence has been used in China since last July, and is now going to be marketed throughout the rest of Asia. The company producing the medicine is NexMed, which is based in New Jersey, USA. The active ingredient in the medication is a derivative of alprostadil ( a medicine for impotence that needs to be injected directly into the penis). Time of onset varies, but typically is much quicker than Viagra. Comment: this company and medication may become wildly popular when it is introduced in the US. [ article ] posted by Internet Medical Journal 15:55 GMT medjournal.com

Fish Oil May Help Diabetics.
Daily supplementation with docosahexaenoic acid was shown to increase insulin sensitivity in overweight individuals susceptible to type II diabetes. Comment: This was a small study of only 12 overweight men and women. Nonetheless, an interesting finding. [ article ] posted by Internet Medical Journal 01:47 GMT medjournal.com

Hormone Replacement and Healthy Arteries.
This small study presented at the 2002 Experimental Biology conference suggests that exercise plus hormone replacement can significantly increase the elasticity of the arteries in women over 60 years old. Comment: elasticity of your arteries is important in the development of cardiovascular disease. This study indicates to me that exercise is vitally important. The role of hormone replacement is still controversial, but in this study it was helpful. The women had to engage in an exercise program consisting of a 40-minute walk 5 times a week. [ article ] posted by Internet Medical Journal 01:42 GMT medjournal.com

Early Life Critical to Lifetime Cancer Risk.
This study of 600,000 immigrants to Sweden found that their lifetime risk of cancer did not differ significantly from that of the country of origin. Comment: an interesting study that hypothesizes that the gestation period for cancer may be decades. The quality of this study appears to be good. The take home message is that parents need to do their best to optimize their children's diet and lifestyle (of course). For example, the eventual development of osteoporosis is highly dependent upon a person's peak bone mass, which in turn is highly dependent upon dietary calcium intake during adolescence. Of particular concern is the large increase in obesity among children over the last 20 years. What will this mean in terms of cancer and heart disease when these children enter their 50's and 60's? [ article ] posted by Internet Medical Journal 01:33 GMT medjournal.com


Monday, April 22, 2002

Sudden Infant Death: Possibly Related to Bacteria in Mattresses.
This study suggests changing mattresses may help prevent suddent infant death (SIDS). Bacteria that grow in mattresses where a baby has vomitted (burped up food) have been linked to SIDS. Foam mattresses, or mattresses that are old or previously used by another baby, are most likely to harbor these bacteria. Comment: based on these findings the use of a non-porous, new mattress for babies seems reasonable. We still don't know very much about how to prevent SIDS. It may be that in the future, more stingent recommendations on the baby's sleeping surface will be made. At this point, it seems reasonable to follow the recommendations of these researchers. [ article ] posted by Internet Medical Journal 04:13 GMT medjournal.com

Afternoon Coffee May Disrupt Sleep.
Comment: Here's a suprising study: drinking coffee in the afterrnoon can keep you awake into the night. So, (surprise!) coffee increases wakefulness. [ article ] posted by Internet Medical Journal 04:01 GMT medjournal.com

Angry Temperment Strongly Linked to Heart Disease.
In this study of 1055 men for an average of 36 years found that hot tempers predicted heart disease long before other risk factors such as diabetes and hypertension. These findings are corroborated by other studies linking type A behavior (high stress) with cardiovascular disease. Comment: the statistics in this study are weak, but suggestive that our intuition is right-- a hostile, angry, negative temperament is not good for your health. [ article ] posted by Internet Medical Journal 03:53 GMT medjournal.com

Exercise Reduces Blood Pressure: So What?.
This meta-analysis of 54 studies found that aerobic exercise reduces systolic blood pressure by 3.8 mm Hg on average, and diastolic BP by 2.58 mm. Comment: this is a classic case of statistics being irrelevant. Why do the authors of this study say that the diastolic pressure is reduced by "2.58" mm Hg? Is there any known difference between that and "2.57" ? This is pure nonsense. Clinically, it appears that the effect upon blood pressure is very minimal. The conclusion of this study should be that we know that exercise is good for you, but don't depend upon exercise to significantly lower your blood pressure. If you have hypertension, you will need to do something more than exercise in order to get your blood pressure down. [ article ] posted by Internet Medical Journal 03:26 GMT medjournal.com
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