Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Latest Posts

The New World View Of Coronary Artery Disease

In 2007, when the results were published from the COURAGE trial, all the experts agreed that this study would fundamentally change the way cardiologists managed patients with stable coronary artery disease (CAD).*

____
*”Stable” CAD simply means that a patient with CAD is not suffering from one of the acute coronary syndromes – ACS, an acute heart attack or unstable angina. At any given time, the large majority of patients with CAD are in a stable condition.
____

But a new study tells us that hasn’t happened. The COURAGE trial has barely budged the way cardiologists treat patients with stable CAD.

Lots of people want to know why. As usual, DrRich is here to help.

The COURAGE trial compared the use of stents vs. drug therapy in patients with stable CAD. Over twenty-two hundred patients were randomized to receive either optimal drug therapy, or optimal drug therapy plus the insertion of stents. Patients were then followed for up to 7 years. Much to the surprise (and consternation) of the world’s cardiologists, there was no significant difference in the incidence of subsequent heart attack or death between the two groups. The addition of stents to optimal drug therapy made no difference in outcomes.

This, decidedly, was a result which was at variance with the Standard Operating Procedure of your average American cardiologist, whose scholarly analysis of the proper treatment of CAD has always distilled down to: “Blockage? Stent!”

But after spending some time trying unsuccessfully to explain away these results, even cardiologists finally had to admit that the COURAGE trial was legitimate, and that it was a game changer. (And to drive the point home, the results of COURAGE have since been reproduced in the BARI-2D trial.) Like it or not, drug therapy ought to be the default treatment for patients with stable CAD, and stents should be used only when drug therapy fails to adequately control symptoms.

When the COURAGE results were initially published they made a huge splash among not only cardiologists, but also the public in general. So cardiologists did not have the luxury of hiding behind (as doctors so often do when a study comes out the “wrong” way) the usual, relative obscurity of most clinical trials. Given the widespread publicity the study generated, it seemed inconceivable that the cardiology community could ignore these results and get away with it.

But a new study, published just last month in JAMA, reveals that ignore COURAGE they have. Read more »

*This blog post was originally published at The Covert Rationing Blog*

Alcohol And Cancer: A Beverage Guide For The Holidays

Guest post submitted by MD Anderson Cancer Center*

When you raise your glass at this year’s holiday toast, choose your beverage wisely. Research shows that drinking even a small amount of alcohol increases your chances of developing cancer, including oral cancer, breast cancer and liver cancer.

Yet, other research shows that drinking small amounts of alcohol may protect the body against coronary heart disease and type 2 diabetes. Some evidence even suggests that red wine may help prevent cancer.

Researchers are still trying to learn more about how alcohol links to cancer. But, convincing evidence does support the fact that heavy drinking damages cells and contributes to cancer development.

Confused? Use our beverage guide to choose a drink with the lowest health risk, and learn your recommended drink limit and what alcoholic drinks to avoid. Read more »

*This blog post was originally published at Health in 30*

American Cancer Society Debunks Prostate Cancer Screening Myths

Dr. Otis Brawley has taken the gloves off on prostate cancer screening.

Brawley, chief medical officer of the American Cancer Society (ACS), makes some powerful statements about controversies in prostate cancer screening in a new YouTube video that is billed as the first of a series that the ACS will post on discussions with its officials.

Key nuggets from this video — not surprising to anyone who has followed this debate or Brawley’s past comments — include these quotes:

I’m very concerned. There’s a lot of publicity out there – some of it by people who want to make money by recruiting patients – that oversimplifies this – that says that ‘prostate cancer screening clearly saves lives.’ That is a lie. We don’t know that for sure…

…We’re very concerned about a number of clinics that are offering mass screening where informed decision making – where a man gets told the truth about screening and is allowed without pressure to make a decision – that’s not happening. Many of these free screening things, by the way, are designed more to get patients for hospitals and clinics and doctors than they are to benefit the patients. That’s a huge ethical issue that needs to be addressed.

We’re not against prostate cancer screening. We’re against a man being duped and deceived into getting prostate cancer screening.” 

*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*

The Global Cost Of Fighting Cancer

Cancer is the world’s costliest disease, sapping the equivalent of 1.5 percent of the global gross domestic product through disability and loss of life, according to the American Cancer Society (ACS). Cancer cost $895 billion in 2008, and that’s before factoring in the cost of treating cancer.

Cancer and other chronic diseases cost more than infectious diseases and even AIDS, according to a report the ACS [presented last] week. While chronic diseases are 60 percent of all deaths globally, they receive only 3 percent of private and public research funding. The organization is calling for a new look at priorities by the United Nations and the World Health Organization. (Associated Press)

*This blog post was originally published at ACP Internist*

More On The False Claims Of A Cancer Researcher At Duke

This is not good. Not good at all.

Recently Paul Goldberg of The Cancer Letter reported on an investigation into Duke cancer researcher Anil Potti, M.D., and claims made that he was a Rhodes Scholar in Australia. The misrepresentation was made on grant applications to National Institutes of Health (NIH) and the American Cancer Society (ACS).

The Cancer Letter, a $375 per year go-to newsletter on cancer research, funding, and drug development, has made this issue free at this PDF link.

News & Observer higher education reporter Eric Ferreri has a nice overview of the situation. Potti has been placed on administrative leave by Duke, and the ACS has suspended payments on his grant and initiated their own investigation. Read more »

*This blog post was originally published at Terra Sigillata*

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…

Read more »

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…

Read more »

See all interviews »

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.

See all cartoons »

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…

Read more »

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…

Read more »

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…

Read more »

See all book reviews »