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Crowd-Sourcing For Medical Diagnoses

The Times ran an intriguing experiment on its Well blog yesterday: a medical problem-solving contest. The challenge, based on the story of a real girl who lives near Philadelphia, drew 1379 posted comments and closed this morning with publication of the answer.

Dr. Lisa Sanders, who moderated the piece, says today that the first submitted correct response came from a California physician; the second came from a Minnesota woman who is not a physician. Evidently she recognized the condition’s manifestations from her experience working with people who have it.

The public contest – and even the concept of using the word “contest” – to solve a real person’s medical condition interests me a lot. This kind of puzzle is, as far as I know, unprecedented apart from the somewhat removed domains of doctors’ journals and on-line platforms intended for physicians, medical school problem-based learning cases, clinical pathological conferences (CPC’s) and fictional TV shows. Read more »

*This blog post was originally published at Medical Lessons*

When Less Is More: Smaller Doses Of Chemo May Be Equally Effective In AML

A recent issue of the New England Journal of Medicine includes an article with the bland title Cytarabine Dose for Acute Myeloid Leukemia. AML is an often-curable form of leukemia characterized by rapidly-growing myeloid white blood cells. Cytarabine — what we’d call “Ara-C” on rounds  — has been a mainstay of AML treatment for decades.

The new report* covers a fairly large, multicenter, randomized trial of adult patients with AML. The researchers, based in the Netherlands, Switzerland, Belgium and Germany, evaluated 860 patients who received either intermediate or high doses of Ara-C in their initial, induction chemotherapy. According to the journal, “this investigator-sponsored study did not involve any pharmaceutical companies.”

The main finding was that at a median follow-up of 5 years there were no significant differences between the groups in terms of complete remission rates, relapses or overall survival. The high-dose Ara-C offered no clear advantage in any prognostic subgroup, including those with genetic changes that bear a poor risk. Not surprisingly, Grade 3 and 4 (severe) toxicities were more common in the patients who received higher doses of Ara-C. Those patients also had lengthier hospitalizations and prolonged reduction in their blood counts.

Why am I mentioning this report, besides that it hasn’t received any press coverage? First, because the findings might matter to people who have AML and are contemplating treatment options. But mainly it’s an example of how carefully dialing down some chemotherapy doses could reduce health care costs and lessen untoward effects of cancer therapy — in terms of early toxicities and, possibly down the line, fewer secondary malignancies – without compromising long-term outcomes.

*subscription required: N Engl J Med 364: 1027–36 (2011). The free abstract includes some details on the chemo doses.

*This blog post was originally published at Medical Lessons*

A New Treatment For Lupus

Lupus, an autoimmune disease, [recently] turned up on the front page of the Wall Street Journal (WSJ). It cropped up, also, on the first page of the New York Times business section, and elsewhere. Scientific American published a nice online review just now. The reason is that the FDA has approved a new monoclonal antibody for treatment of this condition.

The drug belimumab (Benlysta), targets a molecule called BlyS (B-lymphocyte Stimulator). The newspapers uniformly emphasize that this drug marks some sort of triumph for Human Genome Sciences, a biotech company that first reported on BlyS in the journal Science way back in 1999. BlyS triggers B cells to produce antibodies that in patients with lupus tend to bind and destroy their own cells’ needed machinery, causing various joint, lung, liver, kidney, brain, blood vessel and other sometimes life-threatening problems. So if and when Benlysta works, it probably does so by blocking aberrant autoimmune B-cell activity.

The newspapers don’t give a lot of details on the drug’s effectiveness, except that it appears to help roughly one in 11 patients, and the main benefit may be that some lupus patients on Benlysta can reduce their use of steroids, which have long-term and toxic effects on many organs. The most recent major medical publication on a trial on the drug came out in the Lancet two weeks ago.

Some reported caveats are that the drug has not been adequately tested or approved for patients with severe kidney or neurological manifestations of the disease, and that its activity, marginal as it is, appears to be less in patients of African heritage based on trials completed thus far. Additional trials are in the works.

The drug is expensive, to the updated tune of $35,000 per year. According to the WSJ: “Estimates of how many Americans are affected range from 161,000 to 1.5 million.” (How’s that for a wide ballpark figure? Likely a function of how hard it is to define and establish diagnosis for this disease, which anticipates how hard it will be to measure this drug’s effects — see below.) The same WSJ piece says analysts expect the drug to become a blockbuster, with annual sales eventually topping $1 billion. Read more »

*This blog post was originally published at Medical Lessons*

A Helpful Vitamin Chart

Lately I’ve been worrying about Kevin’s refusal to eat broccoli, and wondering what exactly is so good about those green bunches of roughage. In browsing the Web for more detailed information on the matter, I found a helpful vitamin chart.

The table comes from the HHS–sponsored National Women’s Health Information Center — a good spot to know of if you’re a woman looking online for reliable sources. It’s a bit simple for my taste. In the intro, we’re told there are 13 essential vitamins our bodies need. After some basics on Vitamin A — good for the eyes and skin, as you probably knew already — the chart picks up with a quick review of the essential B vitamins 1, 2 ,3 ,5 ,6 , 9 and 12 (my favorite), followed by a rundown on Vitamins C, D, E, H (that would be biotin) and K:

Vitamins, Some of their Actions, and Good Food Sources
Vitamin Actions Sources
A
  • Needed for vision
  • Helps your body fight infections
  • Helps keep your skin healthy
Kale, broccoli, spinach, carrots, squash, sweet potatoes, liver, eggs, whole milk, cream, and cheese.
B1
  • Helps your body use carbohydrates for energy
  • Good for your nervous system
Yeasts, ham and other types of pork, liver, peanuts, whole-grain and fortified cereals and breads, and milk.
B2
  • Helps your body use proteins, carbohydrates, and fats
  • Helps keep your skin healthy
Liver, eggs, cheese, milk, leafy green vegetables, peas, navy beans, lima beans, and whole-grain breads.
B3
  • Helps your body use proteins, carbohydrates, and fats
  • Good for your nervous system and skin
Liver, yeast, bran, peanuts, lean red meats, fish, and poultry.
B5
  • Helps your body use carbohydrates and fats
  • Helps your body make red blood cells
Beef, chicken, lobster, milk, eggs, peanuts, peas, beans, lentils, broccoli, yeast, and whole grains.
B6
  • Helps your body use proteins and fats
  • Good for your nervous system
  • Helps your blood carry oxygen
Liver, whole grains, egg yolk, peanuts, bananas, carrots, and yeast.
B9 (folic acid or folate)
  • Helps your body make and maintain new cells
  • Prevents some birth defects
Green leafy vegetables, liver, yeast, beans, peas, oranges, and fortified cereals and grain products.
B12
  • Helps your body make red blood cells
  • Good for your nervous system
Milk, eggs, liver, poultry, clams, sardines, flounder, herring, eggs, blue cheese, cereals, nutritional yeast, and foods fortified with vitamin B12, including cereals, soy-based beverages, and veggie burgers.
C
  • Needed for healthy bones, blood vessels, and skin
Broccoli, green and red peppers, spinach, brussels sprouts, oranges, grapefruits, tomatoes, potatoes, papayas, strawberries, and cabbage.
D
  • Needed for healthy bones
Fish liver oil, milk and cereals fortified with vitamin D. Your body may make enough vitamin D if you are exposed to sunlight for about 5 to 30 minutes at least twice a week.
E
  • Helps prevent cell damage
  • Helps blood flow
  • Helps repair body tissues
Wheat germ oil, fortified cereals, egg yolk, beef liver, fish, milk, vegetable oils, nuts, fruits, peas, beans, broccoli, and spinach.
H (biotin)
  • Helps your body use carbohydrates and fats
  • Needed for growth of many cells
Liver, egg yolk, soy flour, cereals, yeast, peas, beans, nuts, tomatoes, nuts, green leafy vegetables, and milk.
K
  • Helps in blood clotting
  • Helps form bones
Alfalfa, spinach, cabbage, cheese, spinach, broccoli, brussels sprouts, kale, cabbage, tomatoes, plant oils. Your body usually makes all the vitamin K you need.

(From womenshealth.gov; table accessed 2/19/2011.)

Overall I’d say the chart is useful — a good place to start if you want to know, say, what’s a good, non-citrus source of Vitamin C. It could be improved by provision of more details, like the precise amount of Vitamin B2 per cupful of Swiss chard, and how preparing foods in distinct ways — like roasting, sautéing, boiling, or serving them raw — affects the nutritional value.

*This blog post was originally published at Medical Lessons*

Medical Ethics And The “R” Word

[Recently] a short article in the New York Times, New Kidney Transplant Policy Would Favor Younger Patients, [drew] my attention to a very basic problem in medical ethics: Rationing.

According to the Washington Post coverage, the proposal comes from the United Network for Organ Sharing, a Richmond-based private non-profit group the federal government contracts for allocation of donated organs. From the Times piece:

Under the proposal, patients and kidneys would each be graded, and the healthiest and youngest 20 percent of patients and kidneys would be segregated into a separate pool so that the best kidneys would be given to patients with the longest life expectancies.

This all follows [the recent] front-page business story on the monetary value of life.

I have to admit, I’m glad to see these stories in the media. Any reasoned discussion of policy and reform requires frank talk on healthcare resources which, even in the best of economic times, are limited.

*This blog post was originally published at Medical Lessons*

Latest Interviews

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Caring For Winter Olympians In Sochi: An Interview With Team USA’s Chief Medical Officer Dr. Gloria Beim

I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

Click here for a musical take on over-testing.

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Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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