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Old December 12th, 2002, 07:53
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2002.09.01 General Medical Pearls

Monday, September 30, 2002

Health Insurance Coverage in the US Leaves Many Family Members Out
This report from the National Academy Press found that:

* More than half of the 8 million uninsured children are eligible for Medicaid or a state insurance program (but haven't taken advantage of it)
* One out of five families with children have at least one family member without insurance
* Uninsured newborns are more likely to have low birthweight and die as compared to insured newborns (confounding variables were not accounted for)
Comment: this report highlights the failings of the US's system of linking health insurance coverage to employment. Many entry level jobs will not include health insurance, so those just starting out or at the lower end of the income scale are less likely to have insurance. The result? The weakest and most vulnerable are the least likely to have adequate health care. As an American, I view our current system an embarassment: too much emphasis upon lawsuits (this diverts huge amounts of money into the legal system), too much emphasis upon employment based health insurance, and too little concern for the poor. [ article ]__posted at 9/30/2002 08:22:33 PM by Tom Heston, MD___comment on this article



World Medical Association Condemns Euthanasia as Unethical
A World Medical Association resolution is calling euthanasia unethical, prompting the Royal Dutch Medical Association to call for an open debate over the issue. Comment: Netherlands has passed national laws decriminalizing euthanasia under certain conditions. Oregon state has also passed such laws. [ BMJ 2002;325:675 ( 28 September ) ]__posted at 9/30/2002 07:56:23 PM by Tom Heston, MD___comment on this article



Review: Risks of Long Term Hormone Therapy are Greater Than the Benefits
This review / meta-analysis concludes that long term hormone replacement therapy (HRT) in women increased the risks of breast cancer, stroke, and pulmonary embolism. HRT was shown to decrease the risk of colorectal cancer and femoral neck fractures. There was no significant effect upon endometrial cancer or coronary heart disease. Overall, the authors conclude that the risks are greater than the benefits. Comment: the selective estrogen receptor modulators such as raloxifene (Evista) are looking more and more attractive. [ article ]__posted at 9/30/2002 07:40:06 PM by Tom Heston, MD___comment on this article

Saturday, September 28, 2002

Lancet to Restrict Access to Medical Journal
The online version of the Lancet no longer will be free and unrestricted-- in spite of the numerous "free!" buttons and links on their journal's home page. The change? Now, anyone interested in reading the Lancet will be required to register with the website, and must provide their title, firstname, last name, complete address, email address, medical specialty, and work setting. Comment: the Internet is based upon the priciple that greater communication increases learning and education. Those companies that have chosen to restrict access to important medical information---either by requiring a fee or by denying users their privacy---go against the very heart and soul of the Internet. This decision by the Lancet is truly discouraging, and as a result the Internet Medical Journal will no longer link to the Lancet or support in any way their decision to restrict access to important (and sometimes life saving) medical information. Those sites that choose to restrict access do not foster international communication, education, and understanding. The Internet Medical Journal believes that by providing free online access to medical information, with abundant opportunities for users to provide feedback and communicate with eachother, is the best way websites can promote global compassion and international harmony.__posted at 9/28/2002 05:17:30 PM by Tom Heston, MD___1 comment



Early Evaluation by a Specialist Saves Lives
This study looked at 828 patients with end stage renal disease and found that those patients who were evaluated by a kidney specialist early in their disease lived longer. Comment: this confirms earlier research showing that patients with certain types of diseases benefit from being referred to a specialist early on in their disease. On the flip side, there also has been research showing that primary care providers play an important role in prolonging life, and that those receiving care only from specialists do not receive proper medical care. My practice has been to refer patients to specialists early, but also stay actively involved in their overall health care. [ Ann Internal Med 17 September 2002 Volume 137 Number 6:479. ]__posted at 9/28/2002 03:39:25 AM by Tom Heston, MD___comment on this article

Tuesday, September 24, 2002

Couples Often Get the Same Chronic Diseases
This study looked at 8386 married couples aged 30 - 74 years and found that if either spouse had asthma, depression, hypertension, hyperlipidemia, or peptic ulcer disease, the other spouse was likely to have the same problem as well. This effect persisted even after correcting for age, smoking, obesity, and healthcare provider. Comment: if one partner has a disease, it would be wise to check the other partner for the same disease. [ BMJ 2002;325:636 ( 21 September ) ]__posted at 9/24/2002 01:47:44 AM by Tom Heston, MD___comment on this article

Sunday, September 22, 2002

"Social and political pressure are not criteria for doctors"
The Dutch Medical Association has rejected the opinion of a justice minister and are stating that doctors should not be compelled to force-feed a prisoner in order to allow the prisoner to stand trial. Stating that the ethics guidelines established by the World Medical Association prohibit forcing medical treatment upon a competent patient, the medical association argues that "social and political pressure are not criteria for doctors." Comment: the Dutch Medical Association has taken a strong stand and is to be admired. They have also recently called for a boycott of pharmaceuticals engaging in direct-to-consumer advertising, stating that such advertising increases costs. This has the effect of making healthcare more unaccessible to the poor. [ BMJ 2002;325:615 ( 21 September ) ]__posted at 9/22/2002 11:19:21 PM by Tom Heston, MD___comment on this article

Saturday, September 21, 2002

Celecoxib (Celebrex) Associated With Less Gastrointestinal Bleeding Compared to Rofecoxib (Vioxx)
This study of over 150 000 people over 65 years old found that celecoxib was associated with fewer gastrointestinal bleeds compared with refecoxib, nonsteroidal anti-inflammatory drugs, and diclofenac plus misoprostol. The risk of bleeding in patients taking celecoxib was similar to that of people not taking any nonsteroidal anti-inflammatory drugs. Comment: this is an important study in that it shows that for people at risk of a gastrointestinal hemorrhage, celecoxib does not increase their risk (i.e. acetaminophen / Tylenol is not safer than celecoxib). Furthermore, it shows that celecoxib is safer than rofecoxib for these individuals. [ BMJ 2002;325:624 ( 21 September ) ]__posted at 9/21/2002 10:40:42 PM by Tom Heston, MD___comment on this article

Thursday, September 19, 2002

Pill Splitting Recommended for Certain Medications
This article lists 11 pills as good candidates for pill splitting: Klonopin, Cardura, Celexa, Lipitor, Paxil, Pravachol, Serzone, Viagra, Zestril, Zoloft, and Zyprexa. The authors note that pill splitting must be done with caution as they can become more sensitive to light and the elements. Cost savings is significant. [ AMNews: Sept. 23/30, 2002. 11 pills score as candidates for splitting ... American Medical News__posted at 9/19/2002 06:44:14 PM by Tom Heston, MD___1 comment

Wednesday, September 18, 2002

Radio Broadcast: Medical News, Reviews, and Commentary
Medjournal.com has released a new audio commentary on the week's medical news. [ Click Here to Listen ]__posted at 9/18/2002 04:48:56 AM by Tom Heston, MD___comment on this article

Tuesday, September 17, 2002

Cow's Milk Good for Children's Bone Mass and Stature
This study looked at a total of 250 children aged 3 - 10 years old and found that those who avoided milk had a lower total body bone mineral content (as measured by DEXA scanning) and a shorter stature. Comment: milk really is good for you. The researchers noted that the milk avoiders rarely consumed calcium rich drinks or took mineral supplements. For those children that don't drink milk due to intolerance (40%), milk tastes bad to them (42%), or for personal reasons (18%) a mineral supplement or calcium-rich milk substitute is recommended. [ American Journal of Clinical Nutrition, Vol. 76, No. 3, 675-680, September 2002 ]__posted at 9/17/2002 12:33:40 AM by Tom Heston, MD___comment on this article

Saturday, September 14, 2002

Annual mammography in women in their 40s does not cut death rate
This is a news article from BMJ concerning a previous medjournal.com pearl from the Annals of Internal Medicine. In particular, note the quote from Steven Goodman concerning the risks and benefits of mammography among women in their 40's. It is interesting to note that at the very same time this research came out, new guidelines from the USPSTF recommended mammography among women every 1 to 2 years in their 40's. Comment: considering the findings from this study, perhaps the best approach is self-breast examination regularly, with annual breast examinations from an expert, and mammography beginning in the 50's. We just don't know for sure right now what the best approach is for breast cancer screening. Add to that list the questions over screening for prostate cancer (PSA test?), lung cancer (CT scans?), colon cancer (colonoscopy?). The public health concerns are significant... especially if we view the implications from a global perspective. Here's some of my questions:

* What would be better: annual mammography for American women beginning at age 40, or greater funding of international breastfeeding awareness programs (breastfeeding has been shown to decrease the risk of breast cancer versus bottle feeding by the mother).
* Is mammography harmful? Does it have any negative biological side-effects? How about iatrogenic side-effects (e.g. more radical mastectomies but not longer survival) or economic side-effects? How about international political ramifications?
* Can we use better profiling to better predict who will benefit from mammography in their 40's? How about establishing an online database that would help determine breast cancer risk?

[ BMJ 2002;325:563 ( 14 September ) ]__posted at 9/14/2002 10:40:59 PM by Tom Heston, MD___comment on this article



Nicotine Replacement Therapy Not Very Helpful
This study looked at the effectiveness of nicotine replacement therapy in smoking cessation among California smokers. It found that most people who quit smoking did it on their own (82.8%) while a minority (17.2%) used nicotine replacement therapy, and antidepressant, or both as a smoking cessation aid. Nicotine replacement therapy was not shown to be effective for long-term smoking cessation since 1996. [ JAMA. 2002;288:1260-1264 ]__posted at 9/14/2002 08:55:07 PM by Tom Heston, MD___comment on this article



Surgery More Effective Than Splinting for Carpal Tunnel Syndrome
This study of 176 patients with carpal tunnel syndrome (CTS) found that surgery was more effective than splinting in terms of general improvement, number of nights waking up due to symptoms, and severity of symptoms. Comment: it is important to note that splinting was successful more than half the time (54%) in general improvement at 3 months. Thus the message is that you should try splinting first---and it most likely will work. When splinting fails, surgery will increase the chances of success. [ JAMA. 2002;288:1245-1251 ]__posted at 9/14/2002 08:49:02 PM by Tom Heston, MD___comment on this article

Thursday, September 12, 2002

More FPs stop taking new Medicare patients
More than 1 out of 5 family physicians report that they can no longer take new Medicare patients according to a survey conducted by the American Academy of Family Physicians (AAFP). According to the AAFP president, Warren Jones, MD, the reason is continued cuts in reimbursement by Medicare for physician services. Comment: the overhead associated with running a medical practice is very high. Major expenses include malpractice insurance, emloyee liability insurance, medical record costs, and administrative costs associated with Medicare and Medicaid regulations. The proper way to combat this issue is to either increase Medicare reimbursement (an unlikely scenario) or decrease costs-- such as malpractice insurance. Thanks to the trial lawyers---which consistently state that there are no problems at all with the number of lawsuits in America--meaningful tort reform is unlikely (they have the Senate Democrats firmly in their back pocket). [ FPReport September 2002 Volume 8 Number 9 ]__posted at 9/12/2002 11:39:58 PM by Tom Heston, MD___comment on this article



Sleep Improves Memory
This study found that sleep after practice improved the memory of finger skills. The authors conclude that sleep serves a critical role for storing and optimizing motor skills. Comment: this is exciting news for musicians, especially pianists. The researchers found that sleep right after learning enhanced the speed of sequence performance on average by 33.5% and reduced errors by 30.1% compared to an equal period of wakefulness. Thus, for musicians, athletes, or anyone interested in improving fine motor tasks (such as piano playing or surgical skills), taking a short nap after practicing may be of significant benefit. It may be that surgeons in training would benefit significantly by taking a short nap after learning new surgical skills (this would benefit all of us). This is yet another reason for taking a short nap during the day! [ Proc. Natl. Acad. Sci. USA, Vol. 99, Issue 18, 11987-11991, September 3, 2002 ]__posted at 9/12/2002 04:52:57 PM by Tom Heston, MD___comment on this article

Tuesday, September 10, 2002

Call for Contributors
The Internet Medical Journal is calling for contributors to help write an eBook on How to Prevent a First Heart Attack. [ click here for details ]__posted at 9/10/2002 03:29:59 AM by Tom Heston, MD___comment on this article

Monday, September 09, 2002

Journal Club Free CME Program: ABC of Psychological Medicine--Musculoskeletal Pain
Our journal club has selected a new continuing medical education article on the topic of low back pain. Click Here to view the program online. For information on how to earn Category 1 CME online through our journal club, click here. This program is being offered free of charge.__posted at 9/9/2002 07:31:42 PM by Tom Heston, MD___comment on this article



New Guidelines on Gifts to Physicians
The Royal College of Physicians has issued new guidelines on gifts to physicians from pharmaceutical companies. There currently is a wide variation in policies regarding how pharmaceutical company representatives may interact with physicians. Prior to the 1990's, the practice of giving "gifts" to physicians was rampant throughout most of the world (it was the case in the United States). Currently, for example, in India the practice of giving large exorbitant gifts and even cash incentives to physicians is still commonplace. Comment: the large money involved in marketing new pharmaceuticals has undoubtedly had an effect upon the prescribing practices of physicians. These new guidelines need to be adopted world-wide. [ BMJ 2002;325:511 ( 7 September ) ]__posted at 9/9/2002 06:16:32 PM by Tom Heston, MD___comment on this article

Saturday, September 07, 2002

Telemedicine Cuts Waiting Lists & Maintains Quality
This study of 100 rheumatology patients looked at whether or not having teleconferences with the specialist doctor (a rheumatologist) would cut waiting times and maintain quality, which it did. The teleconference diagnosis was 97% accurate. In contrast, telephone consultations using audio only (not teleconferences which included visual displays) were accurate only 71% of the time. Comment: adding the component of visual interaction made a large difference in quality (an increase from 71% to 97% in accuracy). The same results are likely to be found in regards to Internet medicine. Namely, text only consultations most likely are less accurate than text plus audio, which most likely is even less accurate than text plus audio plus visual. This is pretty obvious. Audiovisual consultations work pretty well (97% accuracy) but how good are text only consultations? The Internet for the next several years will be primarily a text tool for patients to interact with doctors (at least on a large scale) until large scale broadband access is enabled. Text only consultations are likely to be low quality, compared to audiovisual consultations. Do doctors have any business practicing medicine online, and prescribing drugs? It's happening all the time. One prominent online site where doctors practice medicine via only text interaction is kwikmed.com. There are many more. For a blatant example of just how unconcerned mainstream medical journals are about online medicine, see my editorial from June, 1999 titled Ostrich Behavior by Medical Professionals. [ BBC News Sept 1, 2002 ]__posted at 9/7/2002 06:38:04 PM by Tom Heston, MD___comment on this article

Friday, September 06, 2002

Vegetarian Protein as Good as Beef Protein in Weight Training
This study looked at dietary protein sources in 21 elderly men (mean age 65 years) undergoing resistance training. It found that a lactoovovegetarian diet was as good as the beef protein diet in increasing the maximal dynamic strength. This was a 12 week study. [ American Journal of Clinical Nutrition, Vol. 76, No. 3, 511-517, September 2002 ]__posted at 9/6/2002 11:29:12 PM by Tom Heston, MD___1 comment

Thursday, September 05, 2002

Physical Activity Declines Dramatically in Adolescence Among Women
This study of 3379 girls aged 9 to 10 years old, and followed until they were 18 or 19 years old, found that physical activity declined dramatically during adolescence. At baseline, the activity level (in METS) was 27.3 to 30.8 and this decliced to between 0 and 11 by the end of the study. Comment: the authors find it necessary to emphasize black versus white differences, when the real meaning behind this study is that activity decline was dramatic. I believe that this artificial emphasis upon black versus white--- it is even part of the title of the study--- is misleading, devisive, and has no part in medical research. Has political correctness had that profound an effect upon medical research? Apparently yes. In any event, at baseline overall the activity level among the girls was 29.0 METS, and after 10 years the activity level declined to 5.4 METS, a decline of over 80%. This level of physical activity (5.4 METS) is very low--only a little more activity than a full-time couch potato gets. [ NEJM Volume 347:709-715 September 5, 2002 Number 10 ]__posted at 9/5/2002 09:33:02 PM by Tom Heston, MD___comment on this article

Wednesday, September 04, 2002

Journal Club Free CME Program: Clinical Use of C-Reactive Protein
Our journal club has selected a new continuing medical education article on the topic of c-reactive protein. Click Here to view the program online. For information on how to earn Category 1 CME online through our journal club, click here. Currently, this program is being offered free of charge.__posted at 9/4/2002 08:18:25 AM by Tom Heston, MD___comment on this article

Tuesday, September 03, 2002

Journal Club Free CME Program: Recent Advances in Psychiatry
Our journal club has selected a new continuing medical education article on the topic of recent advances in psychiatry. Click Here to view the program online. For information on how to earn Category 1 CME online through our journal club, click here. Currently, this program is being offered free of charge.__posted at 9/3/2002 07:34:48 PM by Tom Heston, MD___comment on this article

Monday, September 02, 2002

Texas Prisons Rate Over Schools
Friday, Aug. 30, 2002. Newsmax.com wires. Texas spends more money on prisons than it does on schools, a new study shows. According to Houston Chronicle reporter Michael Hedges, the study shows that since the mid-1980s the state has increased spending faster on prisons than on education. Wrote Hedges, the Washington-based Justice Policy Institute study also revealed that Texas, now has more black men in state prisons than in state colleges and universities.
But Texas was not the only state where spending on prisons rose along a steep curve over the last 15 years, while money set aside for higher education rose much more slowly, the study revealed.
"Since 1985, the increase in money spent on prisons nationwide topped $20 billion. That is almost twice the increase in dollars spent on colleges and universities," according to the report titled "Cellblocks or Classrooms."
"This report underlines the sad reality that the nation's colleges and universities have lost budget battles to the growing prison system," Vincent Schiraldi, president of JPI and a co-author of the study told Hedges.
State budgetary reports for Texas showed that in 2000 there were about 66,300 African-American men in state prisons, and only 40,872 in state colleges. Hedges reports that over the past 20 years, "the rate of increase in the black male prison population has been four times higher than the increase in black male college students.
"In 1986, Texas spent about $3.1 billion from its general fund on state colleges and universities. That year, $590 million was spent on corrections, or less than one dollar for every five spent on higher education, the JPI study found."
By 2000, however, spending on higher education grew to $4.5 billion while Texas' budget for prisons rose to $2.7 billion. In that period, the amount spent on colleges and universities grew by 47 percent, compared with a 346 percent increase on corrections.
"There is no doubt that criminal justice has been the fastest growing part of the state budget, because of concerns about public safety," state Sen. John Whitmire, D-Houston, vice chairman of the criminal justice committee told Hedges.
Whitmire added that Texas politicians know the issue of being tough on crime resonates with voters. "We have a shortage right now of 40,000 schoolteachers, and 2,500 prison guards, and more is said about filling the guard positions," he said. "Being safe is basic." Whitmire told Hedges he believed the Texas Legislature needed to evaluate the way it allocated dollars to criminal justice and education.
"We have to fight the crime issue by being tough and smart. No one questions that we are being tough enough. We may be coming up short on how smart we have been," he said.
Dianne Clements, of the Texas victim's rights group Justice For All, told Hedges that spending on prisons is a sad but necessary fact of life, and cheaper than alternatives.
"Do we spend too much on prisons? Absolutely. Is it necessary? Without a doubt," she told Hedges. "We'd love to spend that money elsewhere. But as long as people continue to commit violent crimes, we have to protect people. It is a self-defense mechanism."
Clements added, "It is always cheaper to incarcerate someone than to release them, re-arrest them and convict them. We're spending a lot of money on prisons, but we're saving lives and trauma."
Comment: unfortunately, the prison system in the US is not about just locking up violent criminals, its about locking up nonviolent marijuana offenders--- at the price of reducing our investment in education. What are we trying to accomplish? [ article ] Reprinted with permission from newsmax.com __posted at 9/2/2002 05:13:24 AM by Tom Heston, MD___comment on this article

Sunday, September 01, 2002

Review: Stretching Does Not Reduce Muscle Pain or Sports Injuries
This review found five studies in the medical literature on the effect of stretching and muscle pain and sports injuries. The authors conclude that stretching before or after exercise does not decrease muscle soreness and stretching before exercise doesn't seem to help prevent injury. Comment: the major conclusion made by these authors is that "insufficient research has been done..." on this topic. This won't be the last word on this topic. I personally will continue to stretch in spite of the conclusions of this review. [ BMJ 2002;325:468 ( 31 August ) ]__posted at 9/1/2002 04:20:09 AM by Tom Heston, MD___comment on this article
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