Wednesday, February 27, 2019

Doctor, would you mind washing your hands?

Last year was the bicentennial of the birth of Ignaz Semmelweis (1818-1865), a Hungarian obstetrician who saved the lives of thousands of mothers. In the 1800s, "childbed fever" was rampant in maternity hospitals throughout Europe, and about 10% of new mothers died of this poorly understood condition. There were many theories, some quite outlandish, about the cause. In 1846 Semmelweis became the chief of obstetrics at a Vienna hospital. He was able to connect the facts that the rate of childbed fever was much less in a neighboring hospital where midwives did the deliveries than at the hospital where doctors did the deliveries and that the doctors (but not the midwives) attended autopsies before doing their rounds. He figured out that something was carried on the hands of the doctors from the autopsy room, though this was before anyone knew about bacteria and he called the culprit “decomposing animal material.” He began insisting that the doctors at his hospital wash their hands with a chlorine solution after leaving the autopsy room and before examining mothers in labor. The rates of fever and death dramatically dropped after he began this practice. It was a long time before his theory and practice was widely adopted, and only after his untimely early death was his work given the recognition it deserved.
Why is this history lesson relevant to us? In 2019, with all our understanding about infections and how they are spread, about 7% of hospital patients develop an infection while in the hospital, so-called nosocomial infections. In the intensive care unit, this may reach as high as 50%! Most of these infections are still carried on the hands of doctors and nurses from one patient to another. Study after study has shown that less than half of doctors carefully wash their hands between examining patients despite multiple interventions designed to increase this behavior. The introduction of alcohol-based water-less hand washing antiseptic solutions has made the process faster and easier, but even so only a minority routinely use this between seeing every patient. I was able to find at least twenty studies of methods that were used to try to get more health care workers to follow this simple life-saving practice. Most showed at least some improvement, but still rarely achieved compliance much above 50%.
Infections caught in the hospital tend to be nasty ones: MRSA (resistant staph infections), other bacteria that are resistant to most antibiotics, C-diff causing horrible colitis, etc.
So, take matters into your own hands! If you are a patient in the hospital, when a nurse or doctor comes to see you, be obnoxious. I would suggest something on the lines of “Dr. X/Ms. Y, I am really paranoid about getting an infection. Can I ask you to wash your hands before you examine me?” Better to be thought a difficult patient than a sick one.

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Sunday, February 24, 2019

But it was just an over-the-counter pill!

We all get various aches and pains, whether they be headaches, joint pain, backaches or the generalized achiness that goes with many viral illnesses. When we do, we typically reach for something to relieve the pain. These days we are all-too-aware of the problems with narcotics, the most potent pain relievers, and doctors are much more reluctant to prescribe them. There are a lot of non-narcotic alternatives, most of which can be bought off the drugstore shelves without a prescription. Most of these are safe when used in low doses for a short time, but they are not “safe” in the sense that they can be taken at will.
Most non-prescription pain relievers are NSAIDs, non-steroidal anti-inflammatory drugs. These relieve pain by reducing inflammation. The class includes many prescription medications and two widely-available drugs, ibuprofen (Motrin) and naproxen (Aleve). The grand-daddy of all NSAIDs, of course, is aspirin. The most common pain reliever that is not an NSAID is acetaminophen (Tylenol).
NSAIDs reduce inflammation by inhibiting the body’s production of the hormone prostaglandin. While this has the good effect of reducing pain and inflammation, prostaglandin has many other roles in the body. Notably, it protects the stomach by building up the lining, and it helps regulate blood flow to the kidney. Hence, taking large doses of NSAIDs for an extended period can lead to gastritis or ulcers and can result in serious stomach bleeding. This is often made worse because aspirin and all NSAIDs decrease the ability of platelets to stick together and stop bleeding. Particularly in older patients or those with reduced kidney function, but possible in any person, NSAIDs can cause worsening kidney function, which can become permanent if not caught early. A just-published study of young healthy adults (U.S. soldiers) found that even among these low-risk folks, regular use of NSAIDs was linked to acute and chronic kidney disease. Because of their effect on platelets, NSAIDs are particularly hazardous to patients taking blood thinners.
OK, then, I guess it is acetaminophen, right? Used properly, acetaminophen is remarkably free of side effects. However, when used too much, it has its own problem: liver damage. The recommended safe dose of acetaminophen is 3 grams (3000 mg) per day in healthy people. This is the amount found in six “Extra strength Tylenol.” When healthy volunteers took 4 grams/day for a week, three quarters (76%) developed at least mild elevations of their liver tests. Single doses of over 7.5 grams (usually over 15 grams) can cause severe damage to the liver, often irreversible, and acetaminophen overdose is the commonest cause of severe acute liver failure. A key consideration is that acetaminophen is found in many prescription (Percocet, Vicodin, Fioricet) and non-prescription (Tylenol-PM, Actifed, etc.) medications, so be sure to read the label of any pills you are taking. Another important warning is that if you drink alcohol, this is already adversely affecting your liver, so it will be more sensitive to the effects of acetaminophen.
What is one to do? First, the safest option for pain is often non-medication: ice, heat, stretches, massage. If these do not work, acetaminophen in safe doses is the next to try. If you are young and otherwise healthy, up to 3 grams/day. If you drink, keep it to 2 grams/day. Be sure you are not already getting some in other pills you are taking.
If acetaminophen does not work, and it often does not for joint pain, then ibuprofen or naproxen are the next step. This are very similar in effectiveness, though some people get better relief from one than the other. The major difference is in how long they work; ibuprofen typically works for 4 to 6 hours, while naproxen works for 8-12 hours. If you can get by with taking these in the label-recommended dose for a few days, they are generally safe. If you need to take them for a long time, ask your doctor about the need to have your kidney function monitored and/or the advisability of taking medication to protect your stomach.
And remember to try non-medication approaches along with any pills you take!

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Thursday, February 21, 2019

Should you get a shingles shot?

If you had chicken pox as a child, you are at risk of getting shingles.
Most of us old enough to drive had the chicken pox when we were children. A vaccine was first licensed in the U.S. in 1995 and the number of cases of chicken pox peaked in the early 2000’s and have declined steadily since. For most kids, chicken pox was a mild illness, and when I was a child we would have “chicken pox parties” when a case appeared in our neighborhood to get it over with. The virus, however, is sneaky. After recovery, the virus would often go into a dormant resting phase, living in nerve roots near the spine. Our immune system generally kept it from reactivating. As we age, our immune system becomes less robust and can let the virus emerge from its resting phase. Because the virus’s home is at the root of the nerve, it spreads along the course of the nerve. When it does so, we experience pain along the nerve, then a red rash and finally blisters that often form ulcers and eventually heal. This is what we call shingles, known medically as herpes zoster. Shingles is a VERY unpleasant illness. The patient suffers some combination of intense itching and pain for weeks. If the affected nerve is one that serves the face, the eye can be involved and permanent vision impairment can occur. Rarely it can cause deafness if the hearing nerve is involved. The blisters can get a secondary bacterial infection. Rarely, meningitis can occur. Worst of all, since it is affects so many people, 10-20% of shingles victims can develop “post-herpetic neuralgia.” This is intense pain that lasts long after the rash is cleared, often for years, and potentially for life.
OK; shingles is nasty. What can we do to prevent it? First, vaccinate your children. No chicken pox, no later shingles – hopefully 40-50 years from now, shingles will be of historical interest only. For those of us who had chicken pox – and that includes MOST of us 30+ - we must consider getting vaccinated against shingles. If you are 100% sure you never had chicken pox, you can rest easy, but since it was such a mild illness in childhood, it is easy to forget having it. There is a blood test that can tell if you indeed are one of the fortunate few who escaped (and are then at risk of getting chicken pox as an adult – a worse illness!). I ordered the test on about a dozen patients who were sure they had not had chicken pox, and 100% were wrong – they had evidence of having had it.
The first vaccine to prevent shingles was a live attenuated vaccine introduced in 2006, called Zostavax. Live attenuated vaccines use a weakened form of a virus to stimulate our immune system to fight off the real thing. This vaccine was given as a single subcutaneous (under the skin) shot and was very well-tolerated with minimal side effects. The cost is about $160. After being marketed for 10 years, with over 34 million doses used, there were some 23,500 reports of adverse effects, 93% of which were mild. Sounds good – but…unfortunately the vaccine was not as effective as hoped. In the first year after getting the vaccine, the rate of getting shingles was reduced by about 2/3 but by year 7, the protection was less than 50% and by year 11 the reduction in shingles cases was only 38%. The vaccine also proved even less effective in the oldest old, those over 80, who were at greatest risk for both shingles and post-herpetic neuralgia. Also, since the vaccine used a live virus, it could not be used in people with very weak immune systems, such as those on chemotherapy.
Enter the newest contender: Shingrix. This vaccine combines a protein from the virus coat and a naturally-derived “adjuvant,” a non-specific irritant that really juices up the body’s immune system to react to the virus protein. Because there is no live virus in the vaccine, it can be given to patients with compromised immune systems. This vaccine must be given into the muscle and requires two doses, two to six months apart. It is much more effective than Zostavax, giving 97% protection after 3 years, and seems almost as effective in those over 70 as in younger people. What’s the catch? Shingrix has a lot more side-effects than Zostavax. To date, some 84% of people vaccinated reported at least some ill effects, with 17% grading them as severe, compared with 3% of those who got the placebo. Most of these were local soreness and redness, and this generally lasts 2-5 days, though a number of people also felt generally achy and had a fever. The cost for the 2-dose series is about $300, and is covered under Medicare part D plans.
Bottom line: if you or someone close had shingles and you really do not want to get it (and yes, you can get it again), the best way to prevent it is with Shingrix. Try to time it so you can give yourself a few days of R+R and some Tylenol for a few days – do not get it the Friday before a big wedding or competing in the club championship.
Also, since even Shingrix is not 100% effective, it is important to know the signs and symptoms - a painful rash along a very local band of skin anywhere on your body - and it is critical to call your doctor immediately if you see any blisters. There are effective medicines to shorten the course of shingles, but they must be given within 72 hours of the first blister to be most effective. If you note this type of rash late Friday night, you do not need to call the doctor at midnight but do call Saturday morning and do not wait until Monday – and insist on either being seen or treated. With a good description, and perhaps a “selfie” sent as backup, I am comfortable treating shingles over the phone.

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Sunday, February 17, 2019

Are you sure about that? The problem of misdiagnosis

To treat any condition, the doctor needs to know what it is. You would not expect to have your sore ankle treated with penicillin or to have an appendectomy recommended for your sore throat. While this may be self-evident, I know of at least one patient who had a normal appendix removed because the surgeon did not notice the few tell-tale blisters that were warning the careful observer that the lower abdominal pain was due to shingles! I know of several patients who were persuaded to have disk surgery when their back pain was due to arthritis of the spine or muscular in origin; not surprisingly, none of them got any better.
Diagnosis is often easy but at times very hard. A recent review of the disease endometriosis pointed out that there was an average of four to eleven years between a woman first complaining of her symptoms to her doctor and when a diagnosis was made. The National Academy of Medicine has estimated that every one of us is likely to be affected by a misdiagnosis, either in ourselves or a family member. It has certainly affected our family as I detail in Prescription for Bankruptcy. Many misdiagnoses are annoying but not serious, but misdiagnosis has been cited as the number one cause of malpractice suit payouts, and many studies over many years have shown that about 10% of hospital deaths are due to a missed diagnosis.
How can you minimize the likelihood that this will harm you or your loved ones? First of all, be honest and open with your doctors. There is very little you can tell them they have not heard before, and so be frank about your habits and behaviors. When you go for a visit, be sure to get your top priority up front. These days too many doctors are on a treadmill, with limited time for each patient. If you are going in for follow-up of a known problem but you have a new worrisome complaint, get it out there right away. If the doctor thinks they have finished and are about to move on, your new complaint is not likely to get the attention it may deserve.
There are many on-line tools that doctors can use to broaden their approach to diagnosis. I have worked on one, a decision support tool called DXplain, for several decades, and there are others. These can be very useful but they are under-used because doctors are too confident in their own acumen to know when they need to seek help.
When the doctor tells you of a new diagnosis, be prepared to ask them why they think that is what you have: what symptoms or physical exam findings support it. Since the leading cause of misdiagnosis is that the doctor settled on the first explanation for your complaints and did not consider other possible causes, ask them what else it could be – force them to open their mind and at least consider other possible conditions. If they suggest a treatment for this new diagnosis, ask them what you should expect; when you should see improvement and when you should call or return if you do not see improvement. Finally, if you are given a serious new diagnosis, or if the doctor brushes off your complaints as something minor when you are sure it is more serious, do not hesitate to get a second opinion. Second opinions are often very useful. If the second doctor concurs you will have peace of mind, and in many cases they may come up with a better explanation for your complaints.

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Thursday, February 14, 2019

We are what we eat

Doctors tend to treat patients’ ailments and try to prevent disease with pills. It is what we learn most about in medical school. Most doctors give very little attention to diet for several reasons. First, most doctors know little about diet; very little time is spent on diet in medical school curriculums and it is rarely part of our postgraduate education or continuing education courses. We are bombarded with information about drugs in our journals and at medical conventions and we are heavily marketed in our offices by “drug reps,” salespeople for pharmaceutical companies. I never saw a dietician in my office in the 40+ years I practiced. Finally, we are all too well-aware that changing diets is difficult and feel, probably correctly, that it is easier to get our patients to take a pill once daily than it is to change their habits.
At the same time, there is growing evidence that dietary habits have a major influence on our health. Three recent studies brought the point home to me. A report from the long-running Women’s Health Initiative found that frequent eating of fried chicken, fish or shellfish was associated with a higher risk of cardiovascular (CV) disease and death. Another study looked at boys who had fatty liver disease, a condition associated with obesity that has become epidemic in this country. It can go on to cause severe liver disease. They found that a diet low in free sugars resulted in improvement in the liver disease. A third study recently reported looked at the protective effect of a Mediterranean diet on the adverse effects of air pollution in 6 states and two cities in the U.S. Air pollution causes increased cardiovascular disease and death. The people in the study who stuck most closely to a Mediterranean diet had less CV and overall death.
Just as with most topics in medicine, there is a lot of conflicting and confusing information out there. Over the years, I have seen come and go such fads as the Atkins diet, the Scarsdale diet, the “paleo” diet and many others. The only consistent support for health benefits, however, seems to attach to the “Mediterranean diet”. What is this? The Mediterranean diet emphasizes:
• Eating primarily plant-based foods, such as fruits and vegetables, whole grains, legumes and nuts
• Replacing butter with healthy fats such as olive oil and canola oil
• Using herbs and spices instead of salt to flavor foods
• Limiting red meat to no more than a few times a month
• Eating fish and poultry at least twice a week
• Enjoying meals with family and friends. (I think the reason the French live longer is not the red wine so much as it is taking a two-hour break for a leisurely lunch with friends and family.)
• Drinking red wine in moderation (optional). One pleasure doctors don’t have to forbid!
• Getting plenty of exercise
Try it. Hopefully you will like it and you will probably live longer!

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Sunday, February 10, 2019

Should I/he get a PSA test?

Should I have a PSA test?
I expect a lot of feedback on this, as data tends to be overwhelmed by “My (brother-in-law/ golf partner/ accountant) says that the PSA test saved his life.” Read on and react if you wish.
Prostate cancer is the commonest cancer in men (other than low-grade skin cancers), with an estimated 165,000 new diagnoses of prostate cancer in American men in 2018 and about 29,000 deaths. It is increasingly common as men age and at the same time, less likely to lead to death because it is usually a slow-growing cancer. Thus, while it is estimated that the average American male has a 16% risk of developing prostate cancer in his lifetime, he has only a 2.9% risk of dying from it. I would tell my older male patients that if you were to pull all the men over 75 off the golf course and biopsy their prostates, the majority would have cancer. The best data we have shows that by age 80, approximately 60% of men have prostate cancer, but that in most it grows so slowly that they will die of something else before the disease causes any problem.
Historically, prostate cancer was diagnosed by feeling the gland via rectal exam, but this is a very poor way to detect it and certainly useless at picking the disease up early. The approach was dramatically changed when PSA (prostate-specific antigen) came into use as a screening test. There are normally detectable PSA levels in all adult males, and the level rises gradually with age (and the expected enlargement of the prostate that accompanies aging), so the dilemma is in deciding the level that makes cancer likely. Further complicating things is that conditions other than cancer raise the PSA, notably prostatitis (infection of the gland). Both bicycle riding and the rectal prostate exam itself can raise PSA, but usually not by much.
The traditional teaching was that PSA levels under 4 were normal, 4-10 suspicious and over 10 probably cancer, but this simple classification has been questioned. There is no level of PSA that guarantees no cancer, and very big but non-cancerous prostates may have PSA levels over 10. The tradeoff of using lower levels is that fewer cancers are missed but many men who have no cancer will be subject to biopsy. Neither the speed at which the PSA is rising nor the ratio of free to total PSA are definitive enough to give strong recommendations. Hence, if you opt to have your PSA tested, you are accepting the possibility of needing a biopsy. Prostate biopsies are done via the rectum and have been likened to being kicked in the groin by a mule. Multiple samples (8 to 12) are taken and the results are used to calculate a “Gleason score” that grades the cancer and indicates the likelihood of dying from the cancer. There is a small (about 1%) risk of serious infection from a biopsy and similar risk of bleeding
Treating prostate cancer has its own problems. Surgery carries a high likelihood of erectile problems and incontinence of urine, while radiation therapy can cause bowel issues and urinary flow problems.
Multiple studies have been done to estimate the value of screening for prostate cancer, and the results are, to be charitable, inconclusive. A large European trial found that screening would result in 0.7 fewer deaths for every 1000 men screened, while a similar American trial found no difference between men screened and men not screened.
OK then, what should you do? Different groups give different answers, but there is a growing consensus not to screen men over 70 because doing so is unlikely to prolong their life. There is also agreement that it is not worth doing in men under 40 because the disease is so rare. Between 40 and 50 prostate cancer remains rare except in African American men and men with a family history of prostate cancer below age 65, who should follow the same logic as those over 50. For men 50-70, the decision is a classic example of “shared decision making.” Each man will have his own viewpoint on whether the small decrease in mortality is worth the risks of both diagnosis and treatment. In an ideal world, each man would sit down with his doctor and discuss all the issues, but in this day of 10-minute office visits, that is hard to do. Instead, I would suggest you look at one of the web sites that let you explore the pros and cons. My favorites are:

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Tuesday, February 5, 2019

How can we keep Gramps and Granny at home?

Most elders would much rather be in their own homes than in hospitals, but our current health care system seems to be organized around hospitals rather than homes. This is not only less desirable but more expensive.
European and other OECD countries spend much less on health care than does the United States but have better health statistics. This is not necessarily an indictment of U.S. hospitals and doctors on quality (though it is on cost), because there are many differences between the U.S. and our western peer countries besides the way our health care system is organized. Europeans on average are more physically active than Americans, walking and bicycling more, and less likely to be overweight or obese. Another very important difference is that while European countries spend much less on health care, they spend more on a variety of social services, including family and child support and housing. Thus, the U.S. spends about 18% of its gross domestic product on health care, while this is 10-12% of GDP in other OECD nations but public spending on social services represents 21% of GDP in other countries and 19.3% in the U.S. To look at this in another way, for every $1 spent in the U.S. on health care, $0.56 is spent on social services while in other OECD countries, for every $1 spent on health care, $1.70 is spent on social services.
How does this difference in spending priorities affect our health outcomes? As noted in prior postings and in Prescription for Bankruptcy, maternal death rates in the U.S. are dramatically worse than in other OECD nations, and infant death rates are worse even though we have many more neonatal intensive care beds. Much of this can be attributed to the very different ways new mothers are treated. In most OECD countries, generous paid maternity leave is the norm, while in the U.S. if it is offered at all, it is likely to be unpaid. This is clearly a reason why half of new mothers in the U.S. do not even keep their six-week postpartum checks.
Two studies published last fall showed how provision of better social services can impact both quality and cost of health care. One, published in JAMA Internal Medicine in October, looked at the impact of community health workers on the health outcomes of a group of low-income veterans cared for at a Philadelphia VA hospital. These elderly veterans had at least two chronic diseases and lived in high poverty census tracts. Not only did the veterans who were visited by community health workers report greater satisfaction with their health and with their care, but they experienced 65% fewer hospital days over the nine months of the study compared with a similar group who did not have these visits.
A study published the same month in Health Affairs looked at how supportive social services supplied to elderly residents of Queens impacted their hospital use. The group studied were residents of subsidized elder housing units who were matched in every way except that one group had access to a variety of in-home services. These included counselling, home safety assessments, wellness and socialization programs and assistance with accessing government programs and in transportation. The group that got these services, compared to a very similar group living nearby without them, had 32% fewer hospitalizations, and when they were hospitalized, went home sooner.
Increasing social support clearly works. How to finance it is problematic. For large agencies that are globally budgeted, such as the VA or the new Medicare Accountable Care Organizations, a good case can be made for them to plunge in and spend the money and expect a good return on their investment. For the nation as a whole, policy makers must be made to understand that investing in these low-tech services may give a bigger bang for the buck than many other ways the money can be spent. Spending money on improved social support will not only make our most vulnerable citizens happier but in the long run it will save money.

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