The Hormone Debate

The latest analysis of data from the Nurses' Health Study (NHS) suggests that hormone therapy is associated with an increased risk for stroke, regardless of the treatment strategy or the timing of treatment initiation.

This is concerning since hormone therapy was once touted to have protective benefits and physicians were encouraged to place women on hormones for the cardiovascular and bone benefits.

Now as with many other drugs and therapies, the follow-up studies are not always supporting the “science”.

This study found an increased risk of approximately 40% with estrogen alone and 30% with estrogen plus progestin and is nearly identical to that of the Women's Health Initiative study.

This NHS is a prospective, observational study including 121,700 women who were between the ages of 30 and 55 years in 1976 and the subjects were observed with biennial questionnaires, including information on menopause and postmenopausal hormone use as well as cardiovascular risk factors and cardiovascular diagnoses.

Overall, this is a large sample group with good observational data and the bottom line results are:

• Use of hormone therapy by postmenopausal women is associated with overall increased risk for stroke of 30% to 40%.

• An increased risk for stroke associated with hormone therapy use in postmenopausal women is independent of age of initiation of hormone therapy and greater with higher doses of estrogen and older age.

Once again, there are no “free rides” and risks vs. benefits must always be assessed.

Smelly Decision

So how would Obama vote on this issue?

In Farina, Ill., a resident had a love affair with a skunk that began when his brother from Indiana gave him a baby skunk as a wedding gift.

In Indiana, skunks are legal to keep, but across the border in Illinois the animals are seen as a rabies hazard and outlawed.

Most people would never think that owning a skunk is a good idea but this individual believes otherwise.

He says that once you have the animal descented, which is a noninvasive procedure done early in the animal's life, having one is a complete joy.

He says it's like a cross between a house cat and a calm monkey.

This Illinois resident has appealed to his state legislator for help in rescinding the Illinois law, saying the incidence of rabies in skunks is now quite low, but the State representative, Republican lawmaker Ron Stephens, told the paper, "I am keeping an open mind, but I will come down on the side of reason."

Nuclear Medicine

Many people do not realize that there are lots of nuclear medicines used in everyday healthcare.

It is also not well known that half the world's supply is made by a 50-year-old reactor that was temporarily shut down for safety reasons last year.

Canada had plans for a new nuclear reactor but said recently it was scrapping the project.
The Canadian Association of Nuclear Medicine said the announcement was "a major concern".

The current reactor is located at the Chalk River facility in eastern Ontario and is operated by Atomic Energy of Canada Ltd (AECL).

This reactor was supposed to be replaced in 2000 by AECL's MAPLE project, which consisted of two small reactors, but they have been plagued by technical problems and cost overruns and the project was terminated.

Last years shutdown of the current reactor caused a shortage of radioisotopes used in heart tests, cancer tests and other medical procedures.

The current license to operate ends on Oct. 31, 2011 but the government has asked for an extension to ensure the ongoing supply of medical isotopes.

The two MAPLE reactors have cost more than C$500 million to develop but have never worked and never produced medical isotopes. They have been crippled with both technical and economic problems which have remained unresolved.

Last month, the reactors had failed every one in a series of tests.

The government fired the country's top nuclear watchdog in January, saying she had mishandled the NRU closure and Canadian Nuclear Safety Commissioner Linda Keen had refused to allow the reactor to restart after regular maintenance in November, saying not enough safety systems were working.

How this will ultimately affect patient care is yet to be determined, but the shutdown before certainly delayed testing for some of our patients.

Medicare funding

Notice to all physicians and concerned individuals:

The announcement above went out in the past few days and as of Tuesday, the bill was passed with overwhelming support. Our Congressman Baron Hill did support the bill.

It is still important that the legislators here from us regarding this and other issues. These ongoing band-aid fixes is not the solution to the overwhelming problem.

The following link can be used: Government Relations - Indiana State Medical Association

New Medicaid Program

Two counties in Indiana have received a $1.6 million dollar grant from the Centers for Medicaid & Medicare Services, the Indiana Family and Social Services Administration in hopes to reduce costly Emergency Room visits for non-emergency care.

The two counties are Tippecanoe and Marion.

Over the next two years, these counties will create two outpatient care clinics working with Wishard Hospital in Indianapolis and Tippecanoe Community Health Clinic and St. Elizabeth's Hospital in Lafayette to provide services to Medicaid clients from the surrounding counties.

Advanced practice nurses and a patient navigator will staff both clinics.
Patients will also be screened for underlying mental health concerns, such as depression and anxiety.

The attempt is to create something that looks like a retail-based urgent care center but staffed with advanced practice nurses specifically trained with a background in screening and identifying individuals with mental health disorders.

But the problem will still remain that unless Medicaid patients are forced somehow to use these clinics, I do not see things changing.

As most everyone knows, a large percentage of ED visits could be more appropriately addressed in an outpatient setting if the patients just chose to do so.

But the statistics show that nonspecific complaints are very common in the ED and the most common non-emergency visits by Indiana Medicaid patients include complaints of:

• Ear, nose and throat
• Abdominal and back pain
• Headaches
• Anxiety and depression

This project is another attempt to get Medicaid patients to utilize the healthcare system in a more reasonable fashion.

Indiana's Medicaid recipients have a higher ED utilization rate than the national average with an average of 89 visits per 100 Medicaid recipients.

Another one of the goals of the program is to plug people in to a primary care provider for follow-up. But once again, the patients have to do this.

This initiative will also attempt to educate patients on appropriate use of the ED but as long as ED visits remain completely free for Medicaid patients, behaviors are unlikely to change.

We know that people use the emergency room as their family doctor, and that's really inappropriate but when a service costs nothing, there is never an incentive to change or realize the true value.

Over-utilization ties up costly resources and it inhibit Medicaid clients from finding true primary care providers and better overall medical care.

A better solution according to most physicians would be to place a small fee on Medicaid recipients in order to use the ED. A fee of $5 would deter many non-emergent visits and save the Medicaid program millions. The fee could be waived for true emergencies.

Without emphasizing personal and financial responsibility, these other changes will likely not work.

Third World Healthcare

A recent report found that more than 200 million children worldwide under 5 years of age do not receive basic healthcare and this has led to nearly 10 million deaths annually from treatable ailments.

Not surprising, nearly all of the deaths occur in the developing world, with poor children facing twice the risk of dying compared to richer children.

Out of 146 countries surveyed, Sweden, Norway and Iceland were the top ranking countries in terms of well-being for mothers and children.

Nigeria ranked last and eight out of the 10 bottom-ranked countries are in sub-Saharan Africa, where four out of five mothers lose a child.

The top three among the 55 developing countries were the Philippines, Peru and South Africa with Indonesia and Turkmenistan tying for fourth.

A number of health initiatives in the Philippines have been able to successfully cut its child death rate in half since 1990 and the major one was rehydration therapy for diarrhea illnesses whereas only 15 percent of Ethiopian children are able to receive rehydration.

Thirty percent of children in developing countries are not getting basic health intervention like prenatal care, skilled assistance during birth, and basic immunizations and in the Philippines and Peru, the poorest children are 3.2 times more likely to go without essential healthcare compared to their best-off counterparts with the poorest Peruvian children 7.4 times more likely to die than their richest counterparts.

In Latin America, Brazil, Bolivia and Peru have some of the world's widest survival gaps between rich and poor children. In Asia, large disparities also exist in India and Indonesia. Use of existing, low-cost tools and knowledge could save more than 6 million of the 9.7 million children who die yearly from easily preventable or curable causes.

Priorities and society’s decisions on what is important will continue to be debated. Each of these countries make decisions that impact the lives of many and governments do not provide health care to everyone. Individuals worldwide have to make their own decisions and manage with the resources provided. We will continue to see many deaths in developing countries and should feel blessed that we have the resources we do.

Road less well traveled

We may have crowded roads, spaghetti junction and other road hazards, but I don’t’ recall an incident like the one in northern Indiana.

A few weeks ago in Crown Point, Indiana, State road 55 was temporarily closed down because a truckload of human feces spilled onto the roadway.

The driver said he was hauling treated human feces from a water recycling plant in Portage when the load spilled about 10:30 a.m. that morning

The Lake County hazardous materials response team came to clean up the mess, along with the Crown Point Fire Department and Indiana State Police.

Both the northbound and southbound lanes of the highway were closed for hours causing huge delays and problems during the cleanup and the Indiana Department of Transportation cited the driver for an unsecured load.

I am not sure exactly how to secure a load of feces but I guess that is for someone else to determine.

Another Media Pass for Obama

In a reprint from a Real Clear Politics blog, this was another interesting post on how Obama gets off easy without tough questions or any follow-up on some mis-statements. RealClearPolitics - Articles - Obama Needs a History Lesson.

Again this week, he made more misstatements about historical events and how they relate. The media is readily willing to forego truth and ignore his glaring deficiencies, lack of knowledge and experience in order to get him elected.

By Jack Kelly
In his victory speech after the North Carolina primary, Sen. Barack Obama said something that is all the more remarkable for how little it has been remarked upon.

In defending his stated intent to meet with America's enemies without preconditions, Sen. Obama said: "I trust the American people to understand that it is not weakness, but wisdom to talk not just to our friends, but to our enemies, like Roosevelt did, and Kennedy did, and Truman did."

That he made this statement, and that it passed without comment by the journalists covering his speech indicates either breathtaking ignorance of history on the part of both, or deceit.

I assume the Roosevelt to whom Sen. Obama referred is Franklin D. Roosevelt. Our enemies in World War II were Nazi Germany, headed by Adolf Hitler; fascist Italy, headed by Benito Mussolini, and militarist Japan, headed by Hideki Tojo. FDR talked directly with none of them before the outbreak of hostilities, and his policy once war began was unconditional surrender.
FDR died before victory was achieved, and was succeeded by Harry Truman. Truman did not modify the policy of unconditional surrender. He ended that war not with negotiation, but with the atomic bomb.

Harry Truman also was president when North Korea invaded South Korea in June, 1950. President Truman's response was not to call up North Korean dictator Kim Il Sung for a chat. It was to send troops.

Perhaps Sen. Obama is thinking of the meeting FDR and Churchill had with Soviet dictator Josef Stalin in Tehran in December, 1943, and the meetings Truman and Roosevelt had with Stalin at Yalta and Potsdam in February and July, 1945. But Stalin was then a U.S. ally, though one of whom we should have been more wary than FDR and Truman were. Few historians think the agreements reached at Yalta and Potsdam, which in effect consigned Eastern Europe to slavery, are diplomatic models we ought to follow. Even fewer Eastern Europeans think so.

When Stalin's designs became unmistakably clear, President Truman's response wasn't to seek a summit meeting. He sent military aid to Greece, ordered the Berlin airlift and the Marshall Plan, and sent troops to South Korea.

Sen. Obama is on both sounder and softer ground with regard to John F. Kennedy. The new president held a summit meeting with Soviet leader Nikita Khruschev in Vienna in June, 1961.
Elie Abel, who wrote a history of the Cuban missile crisis (The Missiles of October), said the crisis had its genesis in that summit.

"There is reason to believe that Khrushchev took Kennedy's measure in June 1961 and decided this was a young man who would shrink from hard decisions," Mr. Abel wrote. "There is no evidence to support the belief that Khrushchev ever questioned America's power. He questioned only the president's readiness to use it. As he once told Robert Frost, he came to believe that Americans are 'too liberal to fight.'"

That view was supported by New York Times columnist James Reston, who traveled to Vienna with President Kennedy: "Khrushchev had studied the events of the Bay of Pigs," Mr. Reston wrote. "He would have understood if Kennedy had left Castro alone or destroyed him, but when Kennedy was rash enough to strike at Cuba but not bold enough to finish the job, Khrushchev decided he was dealing with an inexperienced young leader who could be intimidated and blackmailed."

It's worth noting that Kennedy then was vastly more experienced than Sen. Obama is now. A combat veteran of World War II, Jack Kennedy served 14 years in Congress before becoming president. Sen. Obama has no military and little work experience, and has been in Congress for less than four years.

The closest historical analogue to Sen. Obama's expressed desire to meet with no preconditions with anti-American dictators such as Iranian president Mahmoud Ahmadinejad is the trip British Prime Minister Neville Chamberlain and French premier Eduoard Daladier took to Munich in September of 1938 to negotiate "peace in our time" with Adolf Hitler. That didn't work out so well.

History is an elective few liberals choose to take these days, noted a poster on the Web log "Hot Air." The lack of historical knowledge among journalists is merely appalling. But in a presidential candidate it's dangerous. As Sir Winston Churchill said:
"Those who fail to learn from history are doomed to repeat it."

FDA slaps Glaxo

In April the Food and Administration (FDA) reprimanded GlaxoSmithKline (GSK) for failing to report all of its post approval data on rosiglitazone (Avandia) which is the company's diabetes drug.

Avandia has received much publicity since May 2007 when a meta-analysis showed a significant increase in the risk of heart attacks and in increase in cardiovascular death.

The FDA sent a letter to the chief executive officer of GSK stating an inspection in late 2007 focusing on compliance with post marketing adverse drug experience reporting requirements failed to report data relating to clinical experience, along with other data and information.

The inspection revealed that the company failed to report multiple post marketing studies involving Avandia.

The FDA stated that nine studies were not disclosed until September 2007 and another 11 studies were not included in required annual reports, although some data were submitted to the agency in other reports or communications.

GSK acknowledged the FDA letter and stated that corrective steps are being taken to "make sure we file periodic reports completely and promptly.

Once again, the information physicians receive from the companies is lacking emphasizing the ongoing need to utilize our own discernment, judgment and experience when treating patients.

As my motto goes; “Never be the first on a drug, or never be the last on a drug”

Gaming for Health

Recently, more than 300 innovators demonstrated new games and discussed key advancements and collaborations across the health and games fields. This conference was held at the Baltimore Convention Center and referred to as the Games for Health Conference.

It was intended to build a convergence between cutting edge gaming technology and healthcare complexities, with an eye toward long-term, breakthrough health solutions.

There were more than two dozen innovative demonstration projects, including application of consumer games, such as Guitar Hero and Nintendo Wii, for self-care, rehabilitation and prevention purposes.

Other games focused on topics from exergaming and physical therapy to epidemiology and cognitive exercise.

The Games for Health Conference was started in 2004 in an attempt to utilize this generation’s love of gaming to promote health and exercise.

The conference provides a forum for collaborations to emerge between the video game industry and the health and health care industry.

There were more than 300 attendees and more than 60 sessions provided by an international array of 75 speakers.

Topics included exergaming, physical therapy, disease management, health behavior change, biofeedback, epidemiology, training, cognitive exercise, nutrition and health education.

The Games for Health Project is produced by the Serious Games Initiative, a Woodrow Wilson International Center for Scholars effort that applies cutting-edge games and game technologies to a range of public and private policy, leadership and management issues.

To date, the project has brought together researchers, medical professionals and game developers to share information about the impact games and game technologies can have on health, health care and policy. For more information, visit http://www.gamesforhealth.org/.

Big Brother

With antibiotic-resistant infections and fears of an upcoming pandemic, the issue of hand washing has continued to be pushed to the forefront.

Hospitals have hand cleaners available throughout the building and physicians, visitors and the staff are constantly being reminded about the protocol.

But researchers at Toronto Rehab have gone a step further and supposedly developed a system that can detect whether hospital workers have washed their hands.

The device is a match-box sized system that hangs around the worker's neck or on a belt and beeps if infra-red detectors suspended over patient beds determine the hands are dirty. How this exactly works is unclear.

This device is not fool proof and it seems to have a few problems. For one thing, it sounds like it only detects when a worker has disinfected using special alcohol dispensers included with the system.

A soap and water washing doesn't count, as far as the system is concerned.

It also can't detect if a health care worker has gone near a patient but not touched him or her.

And if the health care workers view it as an annoyance rather than an asset it would be utterly useless over time.

Although we all need reminders, this is probably more problematic and more of a nuisance for health care workers.

Vactations---it's what's good for you

Just in case anyone ever feels guilty about taking a vacation, there is some data that supports the benefits.

When you are self employed like physicians, you sometimes wonder if vacations are financially worth the cost. After all, when you are not in the office seeing patients, there is no revenue being generated but the overhead of the employees, rent, utilities etc. are ongoing.

The vacation cost then becomes the actual amount paid for the trip plus the amount of lost revenue from not being in the office. It typically does not financially make sense if you look at it purely in a dollars perspective.

But the data now reveals that if we are middle-aged men and what's ailing us is a high risk for heart disease than a vacation certainly makes sense.

Researchers from the State University of New York at Oswego conducted a survey of more than 12,000 men ages 35 to 57 who had participated in a large heart disease prevention trial. The results suggest that men who take vacations every year reduce their overall risk of death by about 20 percent, and their risk of death from heart disease by as much as 30 percent.

Rather than these men being rewarded for their dedication to the job, they suffered the highest overall death rate and highest incidence of heart disease of any of the participants.

What was surprising to some of the researchers was the fact that some of the men surveyed didn't take any vacation time over the five years surveyed.

Stress is thought to influence heart disease in several different ways. Many individuals will self-medicate their stress with smoking and drinking alcohol and they are less likely to participate in leisure activities, hobbies, or get adequate amounts of sleep and exercise.

Vacations tend to counteract these risk factors, even if just temporarily because people tend to pack in more hours of sleep and exercise, as well as spend more time with family and friends while on vacation. All of these are good for the “ol’ ticker”.

Skipping vacations may actually be dangerous to your health and it appears that Vacations have a protective effect because they help you reduce your load of stress, or at least allow you to take a break from the everyday stressors of the workplace.

Luckily, the next generation may be learning from our mistakes as the participants most likely to take regular time off also turned out to be the youngest.

All this said, I am taking my own advice and taking some time off on a much needed vacation.
I’ll begin blogging again in a week or so.

Another benefit of Aspirin

A new study recently published shows that Aspirin can help prevent colorectal cancer.

The study found that aspirin at a dosage of 300 mg or more per day for about 5 years reduced the subsequent incidence of colorectal cancer by 37% overall, and by 74% during the period 10 to 15 years after treatment was started.

These results were published in the May 12 issue of The Lancet.

The investigators did not want to say that the findings were sufficient enough to warrant a recommendation for the general population to use aspirin for cancer prevention.

There remains concern over the potential risks of long-term aspirin use and also the availability of alternative prevention strategies, such as screening.

As with studies of aspirin use in healthy individuals for the primary prevention of cardiovascular disease, the benefit of aspirin is more or less outweighed by the risk of bleeding, but they have not made this determination yet for colon cancer.

If on the other hand, you have a bad family history of colon cancer, the benefit of Aspirin may certainly outweigh the risk.

In other countries where colonoscopies are not readily available, aspirin use could help decrease the incidence of colon cancer.

The optimum dose is still yet to be determined but this study used 325 mg which is higher than that needed for heart disease prevention.

If you are healthy with no stomach related problems and over the age of 40, it might be worthwhile to discuss the option with your physician.

Coordinated care improves outcome

Intensive care unit patients are often on mechanical ventilators and there are always questions about how and when to wean them off and allow them to breathe on their own.

One of the problems is the sometimes disjointed medical care. Nurses are often administering the sedatives but the respiratory therapist is adjusting the ventilator and these two activities weren't happening in a coordinated fashion.

This recent study combined these 2 approaches in a more coordinated fashion.

The study was conducted at 4 tertiary care hospitals and it showed that coordinating mechanical ventilation with sedation results in more days of unassisted breathing and earlier intensive care unit (ICU) discharge for older patients.

This current randomized controlled trial combined spontaneous awakening trials (SATs) with spontaneous breathing trials (SBTs).

Older patients on this combined protocol increased their unassisted breathing time by nearly 4 days during the 28-day study compared with patients in the control group and spent 2 fewer days in a coma and 7 fewer days in ICU.

Investigators noted that both the experimental and control groups had physiologic recovery of respiratory function at the same time but the patients in the control group were not awake enough to have their endotracheal tube removed and come off the ventilator entirely.

Once again, communication among caregivers and a more coordinated approach seems to shorten the time of recovery.

Physicians and all healthcare providers can learn from this approach and attempt to communicate more efficiently.

Medicine and Religious Choice

I still get questions as to why I ask about religious beliefs in my questioning of patients and why it matters in health care. I have addressed many issues in the past, but a recent article in the Archives of Surgery addresses more reasons.

During heart procedures, it is common to use bovine or porcine products for valves etc. But patients of Jewish, Muslim, and Hindu faiths may not accept the use of these animal products based on their religious beliefs and it should be made very clear in the informed consent process whether such products may be used.

After discussion with religious leaders this recent study found that although persons of Jewish faith are prohibited from eating pork, use of porcine products during surgery is permissible.

This is because Judaism considers preservation of life a divine commandment and, therefore, dictates that everything should be done to save a patient.

As in Judaism, consumption of pork is prohibited in the Islamic faith. Use of porcine products for surgery, however, is acceptable as the saving of a life, once again, overrules this prohibition.

But these products should only be used in dire circumstances and after all other alternatives have been exhausted.

The acceptability of using bovine surgical products by persons of Hindu faith may depend on their personal or local cultural view of the sacredness of cattle.

So once again, religious viewpoints do affect how we treat patients and should be part of a complete History of the patient.

As physicians, we should respect our patient's autonomy and have an understanding of worldwide religious views and be sensitive to other religious beliefs.

This understanding of religion and what is acceptable within each can help to shape physicians ideals and enhance our care and practice of medicine.

FDA inspections

The recent contamination of products and drugs entering the USA from foreign countries has heightened our awareness of the lack of oversight.

It is pretty clear that the FDA cannot protect us from all the dangers.

Concern about the FDA oversight was highlighted with the recent contaminant in some batches of blood-thinner heparin that were made with raw ingredients from China.

The Government Accountability Office has stated that the FDA increased inspections of foreign manufacturing sites to about 11 percent last year and took other steps in recent months.

This seems like a very small percentage to guarantee safety of drugs especially when the FDA is so stringent about what can be put on the labeling.

A House of Representatives subcommittee is investigating and will question FDA Commissioner Andrew von Eschenbach about foreign drug inspections. His answers I’m sure will be enlightening.

Most people do not realize that more than 80 percent of the active ingredients in U.S. drugs come from foreign countries and about half of these come from India and China alone.

The estimated cost to inspect all suppliers would be between $67 million and $71 million dollars.

So the question remains; how safe are we?