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

Latest Posts

Counter-Intuitive Results: Several Cancer Screening Tests Don’t Improve Health Outcomes

Nearly forty years ago, President Richard Nixon famously declared a “War on Cancer” by signing the National Cancer Act of 1971. Like the Manhattan Project, the Apollo program that was then landing men on the Moon, and the ongoing (and eventually successful) World Health Organization-led initiative to eradicate smallpox from the face of the Earth, the “War on Cancer” was envisioned as a massive, all-out research and treatment effort. We would bomb cancer into submission with powerful regimens of chemotherapy, experts promised, or, failing that, we would invest in early detection of cancers so that they could be more easily cured at earlier stages.

It was in the spirit of the latter that the National Cancer Institute launched the Prostate, Lung, Colorectal, and Ovarian Cancer (PLCO) Screening trial in 1992. This massive study, which eventually enrolled more than 150,000 men and women between age 55 and 74, was designed to test the widespread belief that screening and early detection of the most common cancers could improve morbidity and mortality in the long term. Not a few influential voices suggested that the many millions of dollars invested in running the trial might be better spent on programs to increase the use of these obviously-effective tests in clinical practice.

They were wrong. As of now, the PLCO study is 0-for-2. Read more »

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*

Should Smokers Be Tested For Lung Cancer With Regular CT Scans?

Lung_cancer_border

If you are a smoker, or love someone who smokes, the specter of lung cancer is ever looming. Wouldn’t it be great if there was a way to detect lung cancer in its earliest and most curable stages, much like the goal of mammograms for breast cancer?

Although it seems like common sense to do such advance checks—a process called lung cancer screening—studies to date haven’t shown that finding lung cancer early translates into fewer deaths from the disease.

A new report in the New England Journal of Medicine suggests that screening heavy smokers with yearly low-dose CT scans can reduce deaths from lung cancer by 20% compared to screening with chest x-rays. The results are from the National Lung Screening Trial, which included more than 53,000 current and former heavy smokers between the ages of 55 and 74. (Preliminary results from this trial were covered in the Harvard Health Letter and in the Harvard Health blog.) Read more »

*This blog post was originally published at Harvard Health Blog*

Behavior Vs. Disease: A New Way To Look At Health

What is the leading cause of death in the United States? Heart disease? Cancer? No, it’s smoking. Smoking? Yes, depending on how you ask the question.

In the early 90s, McGinnis and Foege turned the age-old question of what people die of on its head by asking not what diseases people die of but rather what the causes of these are. Instead of chalking up the death of an older man to say lung cancer, they sought to understand the proximate cause of death, which in the case of lung cancer is largely smoking. Using published data, the researchers performed a simple but profound calculation — they multiplied the mortality rates of leading diseases by the cause-attributable fraction, that proportion of a disease that can be attributed to a particular cause (for example, in lung cancer 90 percent of deaths in men and 80 percent of deaths in women are attributable to smoking). Published in JAMA in 1993, their landmark study became a call to action for the public health community.

When looked at the conventional way, using data from the 2004 update of the original study, heart disease, cancer, and stroke are the leading causes of death, respectively. This accounting may help us understand the nation’s burden of illness, but does little to tell us how to prevent these diseases and improve health. Through the lens of McGinnis and Foege we get the actual causes of death (e.g., the major external modifiable factors that contribute to death). This analysis shows that the number one cause of death in America is tobacco use, followed closely by poor diet and lack of physical activity, and then alcohol consumption. Read more »

*This blog post was originally published at BeyondApples.Org*

“I Smell (Health) Trouble”

I was surfing around the Net one day and I found this article about scientists who are creating a machine that will detect acetone in someone’s breath. Acetone can be a sign that someone suffers from diabetes, so in theory this machine could use scent to diagnose this disease.

That story brought to mind other stories I’ve heard about people using dogs to sniff out cancer in people. According to this article:

“The results of the study showed that dogs can detect breast and lung cancer with sensitivity and specificity between 88% and 97%. The high accuracy persisted even after results were adjusted to take into account whether the lung cancer patients were currently smokers. Moreover, the study also confirmed that the trained dogs could even detect the early stages of lung cancer, as well as early breast cancer.”

People have even tried “smelling” schizophrenia. Read more »

*This blog post was originally published at Shrink Rap*

Lung Cancer CT Scan Marketing Spreads Across The Country

Last week, after the National Lung Screening Trial results were released, David Sampson, American Cancer Society director of medical and scientific communications, wrote that “our greatest fear was that forces with an economic interest in the test would sidestep the scientific process and use the release of the data to start promoting CT scans. Frankly, even we are surprised how quickly that has happened.”

And, yes, the marketing has even hit fly-over country in the Twin Cities, with this ad appearing in the Sunday Minneapolis Star Tribune in the “A” section:

scan.jpg

Of course, no where in the ad will you read about the potential harms of such scans, the false positive rate, what happens when you get a false positive (unnecessary followup testing and perhaps unnecessary treatment), and more costs. And nowhere in the ad will you read that 300 heavy smokers had to be scanned in order for just one to get a benefit of extending his life. But six clinics in this chain are standing by to take your money and do your scan.

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

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 »