– by Dr. Irving Loh, MD

An interesting article (1) last month in Circulation: Cardiovascular Quality and Outcomes quantified something that has been quite subjective for experienced clinicians when dealing with coronary heart disease patients. When objectively diagnosed with stress and depression, CHD patients had a 48% higher risk of increased MI or death in 2.5 years of followup compared to the low stress and depression cohort. As a profession, it looks like we’re all in big trouble.

This study came out of Columbia University in New York and was lead by Dr. Carmela Alcántara. They examined the profiles of 4487 patients aged 45 or older enrolled in the Reasons for Geographic and Racial Differences in Stroke study and thus were known to have coronary heart disease. From 2003 to 2007, patients were interviewed at home or asked by questionnaires how often during the past week they felt depressed, lonely or sad, or had crying spells. They were also asked how often they felt unable to control important things in their lives, felt overwhelmed, felt confidence in their ability to handle personal problems and felt things were going their way during the past month. The implications of unrecognized or inadequately treated stress and depression can be manifested internally by adverse cardiovascular outcomes or externally as with the co-pilot of the Germanwings tragedy last month.

It was determined that it was the interaction between self-reported stress and depression, rather than just each independently that seemed to be related to the outcome measures, though no clear causal mechanism was discerned. Each of these symptoms separately did not seem to increase risk. Segregation of these factors as clinicians know is hardly a clean science, so their cohabitation in an affected patient is enough to warrant more focused attention on not only the patient’s cardiovascular risk factors, but on mitigating the psychosocial exacerbation of major cardiovascular adverse event risk. We all know about the sophisticated lifestyle and pharmacologic strategies needed to manage the classic cardiovascular risk factors. This study suggests that there may remain significant gaps in psychosocial care that may have similar implications for clinical outcomes. Indeed, coronary heart disease is a process that trends in the older population, and there are inadequately addressed issues in both the medical and sociological arenas that can alleviate the stress and depression that disproportionately afflict the elderly.

A multidisciplinary team approach with targeted care coordination is needed. Our society generally and our healthcare system specifically are not well prepared to effectively manage this scenario, but with a potentially manageable 50% increased risk, perhaps we need to implement concepts like care circles and care coordination tools like Tiatros™ (reader warning: I am a Tiatros™ advisor, so it’s one with which I am familiar, but there are other similar programs as well so no product endorsement should be interpreted or implied) that can help alert the care giver team. More research is required to determine mechanisms and optimal interventions to positively effect outcomes.
References:

1. http://bit.ly/1B1S14d Circulation: Cardiovascular Quality and Outcomes, online March 10, 2015

Bio:

Dr. Irving Kent Loh MD, FACC, FAHA (Epidemiology & Prevention), FCCP, FACP is a board certified internist and sub-specialty board certified cardiac specialist with an emphasis on preventive cardiology. He founded and directs the Ventura Heart Institute, which conducts education, research and preventive cardiovascular programs. Dr. Loh is a former Assistant Professor of Medicine at UCLA School of Medicine. He is Chief Medical Officer and Co-founder of Infermedica, an artificial intelligence company for enhancing clinical decision support for patients and healthcare providers.

The post Stress and Depression Increase Heart Risk appeared first on Sermo.

~Dennis Morgan, MD

Chemotherapy is one of the miracles of modern medicine. It is also the proverbial two-edged sword — curative or deadly. Doses, schedules and routes are carefully explored in clinical trials and guidelines published. But the actual administration is very complex and the margin for error very small. Despite abundant literature on how to reduce errors, dangers lurk within every infusion center. I recount here some experiences intended as an exercise in mindfulness — a reminder to learn and re-learn the principles of safe administration.

When I was a resident physician I was called one evening at midnight to administer a dose of vincristine. I met the nurse in the med room as she was loading a syringe. Handing it to me, she complained how cumbersome it was to draw up all ten vials that the pharmacy sent up. Some readers will gasp at this point. Vincristine comes in 2 mg vials. I was just handed 20 mg — a potentially fatal dose. The decimal point had not transferred to the carbon copy of the order.

The transcription error was caught because I had a pattern recognition for this drug. I knew the dose formula (1.4 mg/m2 — max 2 mg) and that it came in 2 mg vials. Early on in my residency I had taken an interest in oncology and was possibly the only house officer in that thousand bed hospital who knew instinctively that ten vials is a life-threatening dose. (Vincristine later became notorious for death due to inadvertent intrathecal administration).

This concept of a pattern recognition for the template of any given treatment shaped my habits in practice. I kept my repertoire of regimens as small as possible such that my staff and I were intimately familiar with each one. However some regimens are unavoidably complex. Experimental ones are fraught with peril since so few are familiar with the template. So it was in the notorious cases of a fatal overdose at a revered teaching hospital in Boston when a patient, a well-known health care reporter, died from an overdose due to misinterpretation of an order: 4 grams of cytoxan was given not over four days, but each day(1). The error was not recognized as a deviation by those downstream in the chain of treatment — it was masked by the eccentricity that attends experimental regimens.

There are plenty of cases where the wrong drug was given due to the problem of look-alike, sound-alike drugs (LASA)(2). As a fellow I was privy to a fatal case of a nursing home patient given daily Uracil mustard instead of the bladder analgesic Urised. There are many problematic pairs (e.g. vincristine — vinblastine)(). Precautions have included changing names (mithramycin was changed to plicamycin to distinguish it from mitomycin), the use of TALL MAN notation (vinCRIStine — vinBLAStine)(3), and computerized order entry (CPOE)(4). Entire drug regimens can suffer from this type of confusion. We had occasion to round with a nurse who had co-authored a well-known handbook on chemotherapy regimens. I declared I wanted to treat a patient with “COP-”.  She astutely pinned me down: did I mean to give COPP or COP (the later not to be confused with CVP — same drugs, different dose).

Returning to the dose issue, I became meticulous about accuracy. My policy was at least two qualified people doing calculations at least twice each. Nonetheless I once ordered a dose of bleomycin much bigger than indicated. I had referenced a handbook in common use — but there was a typographical error. The fault was a failure of pattern recognition on my part, for the first cycle anyway.

That it will be the intended patient who gets the treatment should not to be taken for granted — identity checks are crucial. Consider two extensions of the concept of “the right patient”. One is having the right diagnosis. When I was interning in pathology we encountered a case of a revised diagnosis. A medicine resident had received several months of chemotherapy for osteogenic sarcoma. The new chief of pathology recognized the true diagnosis — benign myositis ossificans. The other extension to ‘right patient’ is the ‘ready patient’. I suspect every oncologist has regretted at least once not having the chem profile or blood counts before the drug was given.

Aside from the issue of skill set, the following illustrates the value of the patient as a team member in reducing errors. I was as an expert witness in a case of severe extravasation. A physician had substituted on a weekend for the oncology nurse. While the doctor pushed on the syringe of mitomycin the patient said his arm hurt — but it never hurt before, when his nurse gave his medication from a hanging bag. The doctor persisted and the patient ended up with a hole in his arm. Fortunately, there is now a trend to actively recruit patients in the process of  trapping errors(5).

A recent study in a community outpatient infusion center concluded “The incidence of errors capable of causing harm was reduced from 4.2% with handwritten orders to 1.5% with preprinted orders … to 0.1% with CPOE”(4). I suspect many infusion centers are not doing as well. Constant vigilance is required to reduce errors and even improve on a 0.1% rate of harm, including death. Remember if it happens to your patient it is 100% for them. The essential principles and procedures are delineated in the ASCO/ONS guidelines(6) and in a comprehensive handbook by the Director of Pharmacy at Fox Chase Cancer Center(7), amongst many others(8). Monitoring outpatient use of oral chemotherapy is a special challenge.

To engrain in them the habit of safety every fellow should ‘push chemo’ as part of their training. They should at least once experience their mind second-guessing each calculation and their eyes second-guessing the hands as they dilute and draw up a measure of drug with the power to cure or kill. The sensation of holding a two-edge sword by the blade should follow them through the years of wielding a prescription pen.

What experiences have informed your own approach to chemotherapy safety?

We discuss this and a myriad of clinical topics inside SERMO. If you’re an M.D. or D.O., please join us.

Bio

Dennis Morgan, MD is Assistant Clinical Professor University of Connecticut Health Center, Emeritus Staff Johnson Memorial Hospital and Medical Center Stafford CT and Past President Connecticut Oncology Association as well as Past Medical Director Phoenix Community Cancer Center, Enfield CT

References

(1) Betsy Lehman Center for Patient Safety and Medical Error Reduction

http://www.mass.gov/chia/consumer/betsy-lehman-…

(2) Look-alike, sound-alike drugs in oncology. Kovocic L, Chambers C. J Oncol Pharm Pract. 2011 Jun;17(2):104-18.

http://opp.sagepub.com/content/17/2/104.abstract

(3) Application of TALLman Lettering for Drugs Used in Oncology. ISMP Canada Safety Bulletin. Volume 10, Number 8 November 11, 2010.

http://www.ismp-canada.org/download/safetyBulle…

(4) Reduction in Chemotherapy Order Errors With Computerized Physician Order Entry. Meisenberg BR et al. JOP January 2014 vol. 10 no. 1 e5-e9.

http://jop.ascopubs.org/content/10/1/e5.abstract

(5) Medication errors in chemotherapy: incidence, types and involvement of patients in prevention. A review of the literature. Schwappach DLB, Wernli M. (2010) European Journal of Cancer Care 19, 285–292.

http://onlinelibrary.wiley.com/doi/10.1111/j.13…

(6) 2013 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards Including Standards for the Safe Administration and Management of Oral Chemotherapy. Neuss MN et al. J Oncol Pract. 2013 Mar;9(2 Suppl):5s-13s.

http://www.instituteforquality.org/sites/instit…

(7) Guide To The Prevention Of Chemotherapy Medication Errors, 2nd Edition. Kloth DD. McMahon Publishing, Abraxis BioScience. 2010.

http://www.clinicaloncology.com/download/pg1012…

(8) Preventing Medication Errors in Cancer Chemotherapy. (Textbook Chapter 16).Learning Aids: Medication Errors, 2nd Edition. Cohen MR, ed.  [See Lecture 6].

http://www.pharmacist.com/learning-aids-medicat…

The post Chemotherapy: Safety is No Accident appeared first on Sermo.

~Dr Cedric Cheung

We all know antibiotic resistance is a major health problem. Take, for example, resistant Acinetobacter baumanii (AB) ventilator-associated pneumonia and bacteremia that are major issues in hospitals all over the world. What should clinicians do when confronted with a sputum or blood culture that grows out multi-drug resistant (MDR) AB? What would you do? Hopefully you would call an ID consult (shameless plug), but what should ID do?

Unlike methicillin resistant Staphylococcus aureus infections where there are many recently developed antibiotics to choose from, the pipeline of novel agents to treat infections due to MDR AB and other gram-negative rods like Klebsiella pneumoniae and Pseudomonas aeruginosa has been dry for decades. We can only resort to dusting off some long forgotten antibiotics like colistin (with all its nephro and neurotoxicity) or as in the December 2014 supplemental issue of Clinical Infectious Diseases, using minocycline (a tetracycline class antibiotic) for resistant AB infection. That’s right, the antibiotic probably best known for treating teenage acne is actually being considered to combat one of the meanest, nastiest scourges of the ICU.

Normally, it is probably best to use combination therapy of a carbapenem or ampicillin/sulbactam and colistin for empiric treatment of AB infection, as in vitro studies have shown synergistic effect. If susceptibility results show sensitivity to ampicillin/sulbactam, cefepime, or a carbapenem, de-escalation to monotherapy is reasonable. However, if the susceptibility report comes back as MDR AB, you’ve got a problem, and this is not an uncommon problem. A study of over 5000 AB isolates collected from 2007 to 2011 from different regions of the world showed alarming resistance rates to ampicillin/sulbactam (75%) , imipenem (63%), cefepime (78%), and amikacin (65%) [1]. Thankfully, colistin still retains consistent activity against AB (99% susceptible), in addition, minocycline susceptibility was found to be decent (79%). Treating MDR AB is complicated, but most likely a combination of colistin plus something can be effective. This is where minocycline could come into play.

In a case series of 55 patients with MDR AB infection [2], the combination of colistin plus IV minocycline showed the best clinical success (74%). Other smaller case series showed similar results that seem to support the use of minocycline in these difficult to treat infections [3]. In fact, one center is using colistin and minocycline as empiric therapy of AB infections until antibiotic susceptibility is known [2].

I apologize if this article was a little too “hardcore ID” for you, but my intention is to highlight the difficulties in treating superbugs such as AB and the need for novel treatments. If I ended it here, this would be just another depressing lament about antibiotic resistance.  Stay tuned for part 2 of this article, where I will share the exciting story of the discovery of teixobactin published last month in Nature that could be a game changer.

Are resistant “superbugs” a real problem in your facility?  Which ones in particular?

We discuss this and a myriad of clinical topics inside SERMO. If you’re an M.D. or D.O., please join us.

References

1. Castanheira M, Mendes, RE, Jones RN. Update on Acinetobacter Species: Mechanisms of Antimicrobial Resistance and Contemporary In Vitro Activity of Minocycline and Other Treatment Options. Clinical Infectious Diseases 2014;59(S6):S367-73.
2. Goff DA, Bauer KA, Mangino JE. Bad Bugs Need Old Drugs: A Stewardship Program’s Evaluation of Minocycline for Multidrug-Resistant Acinetobacter baumanii Infections. Clinical Infectious Diseases 2014;59(S6):S381-7.
3. Ritchie DJ, Garavaglia-Wison A. A Review of Intravenous Minocycline for the Treatment of Multidrug-Resistant Acinetobacter. Clinical Infectious Diseases 2014;59(S6):S374-80.

Dr Cedric Cheung Bio

After graduating from Johns Hopkins University Cedric attended Albert Einstein College of Medicine.  Fascinated by a 2 foot long Ascaris worm in a jar being passed around in parasitology class, he instantly fell in love with infectious diseases.  So after completing his residency in internal medicine from New York University he returned to Einstein for his ID fellowship.  He stayed in the Bronx working for St Barnabas Hospital in the Designated AIDS Center caring for HIV patients.  He currently the director of HIV services for MSI Professional Services in China.

The post Antibiotic resistance: desperate and hopeful times appeared first on Sermo.

~by Jennifer Hanrahan, D.O.

Whenever I talk to healthcare workers about vaccines, there is always a group of people waiting to inform me of the dangers of vaccines. The first time this happened, I was surprised. It seemed strange that people whose lives are dedicated to helping others based on science would become part of the anti-vaccine movement. I am going to speak about this topic, knowing that there will be some negative responses.

Nothing in modern medicine has saved as many lives as vaccines. Debilitating, fatal diseases are now often a thing of the past. The great success of vaccines has allowed us to forget about horrible diseases that used to occur regularly. Because we don’t have to see these diseases, we have the luxury to debate the merits of vaccines. Every time a new epidemic occurs, the first question is whether there is a vaccine or whether one could be developed. Thousands of lives and untold human suffering would have been spared if a vaccine for Ebola were available.

Before routine vaccination, there were 13,000-20,000 cases of paralytic polio in the U.S. every year. The last case occurred here in 1979. There were 20,000 cases of congenital rubella syndrome annually prior to rubella vaccination. Before routine measles vaccination, almost everyone in the U.S. got measles. Some went on to have terrible complications such as subacute sclerosing panencephalitis, which ended in death. Fortunately, measles is uncommon in developed countries now. In 2004, there were an estimated 454,000 measles deaths, which translates into more than 1,200 deaths every day or 50 people dying every hour from measles. In 2013, this number decreased to 16 deaths per hour from measles, due to ongoing vaccination efforts. Almost 16 million deaths were averted due to measles vaccines administered from 2000-2013.

Bacterial meningitis used to be an early childhood illness.  Due to vaccination programs for H. influenzae type B and pneumococcus, the average age of bacterial meningitis is now 41.9 years.

Measles, Rubella, Smallpox, Polio, bacterial meningitis in children- all of these are almost diseases of the past, because vaccines work. Despite their great success, people are eager to believe myths about vaccines, and choose not to get themselves, or their children vaccinated. Keeping all of these diseases in the past requires herd immunity. Even a small decrease in herd immunity leads to reemergence of disease.

After the publication of a paper in Lancet in 1998 by Wakefield, et al. vaccination rates decreased, and in 2008, measles and rubella were declared endemic again in the U.K.

This paper was fabricated by the author and was retracted by Lancet. The authors were investigated and barred from practicing medicine in the U.K. Still; many people choose to believe that there is a link between vaccines and autism, as well as myriad other ailments.

How people make decisions has little to do with data, and more to do with emotions. This topic is investigated and described in a great book, “Mistakes were made, but not by me,” by Carol Tavris and Elliot Aronson. Once a decision is made, all additional data is used to support the decision. Even data that clearly goes against the opinion is used as further support. Physicians are, unfortunately, not immune to this phenomena.

A new vaccine was just released for prevention of HPV. Gardasil 9 includes five additional strains of HPV. Many of the patients I see, who would have been eligible for vaccination, have not received HPV vaccines, and by the time I see them, they are older than 26, and no longer eligible. I am hoping that doctors will think more about immunizing adults, and help to prevent suffering.

What are your experiences with anti-vaxxers? Do you find it difficult to keep up with all of the changing recommendations for vaccinations?

We discuss this and a myriad of clinical topics inside SERMO. If you’re an M.D. or D.O., please join us.

References:

1. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(97)11096-0/abstract

2. http://www.who.int/mediacentre/factsheets/fs286/en/

3. Thigpen MC, Whitney CG, Messonnier NE, Zell ER, Lynfield R, Hadler JL, et al. Emerging Infections Programs Network. Bacterial meningitis in the United States, 1998-2007. N Engl J Med. 2011;364:2016-25.

4. http://www.americanscientist.org/bookshelf/pub/an-interview-with-carol-tavris

Jennifer Hanrahan, D.O. is an infectious disease physician at MetroHealth Medical Center and is medical director of infection prevention at MetroHealth Medical Center. She has served as co-medical director of the Cleveland Department of Public Health, and has extensive experience teaching residents, fellows and medical students. Her areas of expertise include influenza, hospital-acquired infections, legionella, HIV/AIDS, and hospital preparedness for infectious diseases.

The post Vaccines: the most important part of modern Medicine appeared first on Sermo.

~ by Linda M. Girgis, MD

We have started to explore the complications obesity can cause. This post will look at its association with sleep apnea. The role of obesity in sleep apnea has been well established in adults and children alike. Its rate has been climbing.

The prevalence of OSA in obese patients is nearly twice that of normal weight patients. Patients with mild OSA who gain 10% of their baseline weight have at a sixfold-increased risk of progression of OSA.  Similarly, a loss of an equal amount of weight can lead to more than 20% improvement in OSA severity. Some recent studies show that obese children have a 46% prevalence of OSA when compared with children seen in a general pediatric clinic (33%).

Why does obesity cause OSA?

It is felt that deposits of fat in specific areas play a key in determining whether someone develops OSA. For instance, fat deposits in the tissues surrounding the upper airways can result in a narrower lumen and increased collapsibility of the upper airway.  In addition, truncal obesity reduces chest compliance, functional residual capacity, and increased demand for oxygen.  Nevertheless, the relationship between OSA and obesity is much more complex.  Patients with OSA tend to have reduced physical activity and cravings for carbohydrates that tend to exacerbate the obesity.  CPAP has been shown to reduce the visceral fat in some patients.  There have been some studies showing an interplay of obesity and OSA as a result of genetic factors, specifically polymorphisms of the leptin receptor.

It is even more alarming that we see  this more frequently in children and adolescents.  In one study, 46 children were evaluated. These subjects were recruited from a pediatric obesity clinic at a university hospital. They had been referred there by their primary care providers. They were compared to 44 normal weight subjects who were matched for other characteristics, such as sex and age.  This study showed that mild breathing disruptions, however, they were more significant in obese subjects. It was also shown that many of them had enlarged tonsils and adenoids, so suggested ENT consult in cases of OSA in children despite their BMI. An interesting observation in this study is that oxygen desaturations were not as severe as in adults with OSA and, therefore, children with OSA did not suffer from daytime sleepiness as much.

The Sleep AHEAD study showed that there was a clear improvement in OSA in patients who lost weight.  This study included 264 subjects in 4 different centers.  Their average BMI was 36.7 and average apnea-hypopnea index (API) 23.2 events per hour. This study showed that clearly weight loss improved OSA, especially in men and those with higher AHI scores.   In patients who maintained their weight for one year, they maintained their benefits of their weight loss as evidenced by their repeated AHI scores.

Obesity clearly plays an etiologic role in OSA in both adults and children. We are learning the dangers of OSA as time goes on, in terms of hypertension and cardiovascular disease.  While obesity itself has a clear cause of producing OSB, it appears to be multi-factorial. Weight loss has been clearly demonstrated to improve OSA in many studies. The treatment should start with lifestyle changes and weight loss.

We discuss this and a myriad of clinical topics inside SERMO. If you’re an M.D. or D.O., please join us.

Bio

Dr. Linda Girgis MD, FAAFP is a family physician in South River, New Jersey. She has been in private practice since 2001. She holds board certification from the American Board of Family Medicine and is affiliated with St. Peter’s University Hospital and Raritan Bay Hospital. She teaches medical students and residents from Drexel University, UMDNJ, and other institutions.  Dr. Girgis earned her medical degree from St. George’s University School of Medicine. She completed her internship and residency at Sacred Heart Hospital, through Temple University.  She has appeared in US News and on NBC Nightly News.

The post Obesity and Sleep Apnea appeared first on Sermo.

The American Medical Association (AMA) and the Centers for Disease Control and Prevention (CDC) announced the launch of their joint initiative, Prevent Diabetes STAT today.  The incidence of diabetes is rising at an alarming rate, with nearly 90% of the 86 million Americans living with prediabetes unaware they have it.

Dr. Linda Girgis, MD echos this urgency, saying “There are many people out there who are diabetic that we have just not diagnosed yet. Diabetes, as a natural course of its progression, gives rise to complications the longer a patient has it. For example, changes in the eye and kidney can take place within 5 years of onset of the disease. That is why it is imperative to diagnosis diabetes early.”

“It’s time that the nation comes together to take immediate action to help prevent diabetes before it starts,” said AMA President Robert M. Wah, M.D. “Type 2 diabetes is one of our nation’s leading causes of suffering and death—with one out of three people at risk of developing the disease in their lifetime. To address and reverse this alarming national trend, America needs frontline physicians and other health care professionals as well as key stakeholders such as employers, insurers, and community organizations to mobilize and create stronger linkages between the care delivery system, our communities and the patients we serve.”

“The time to act is now. We need a national, concerted effort to prevent additional cases of type 2 diabetes in our nation – and we need it now,” said Ann Albright, Ph.D., R.D., director of CDC’s Division of Diabetes Translation. “We have the scientific evidence and we’ve built the infrastructure to do something about it, but far too few people know they have prediabetes and that they can take action to prevent or delay developing type 2 diabetes.”

Girgis, a family physician in South River, New Jersey, shared that 20-30% of her patients are diabetic or prediabetic, putting them at a much greater risk of heart and kidney disease.  Research shows that the progression of the disease can be slowed if action is taken in the prediabetic stage.

The AMA and CDC have co-developed a toolkit that includes information on screening high-risk patients, engaging them (including resources you can share with them), referral forms and documents about how to integrate these into their practices.  There are also resources for patients to help them know the risk factors and determine their own risk for type 2 diabetes at www.preventdiabetesstat.org.

Other resources available from the CDC and AMA are the National Diabetes Prevention Program (National DPP) and the Improving Health Outcomes initiative respectively.

“Our health care system simply cannot sustain the continued increases in the number of people developing diabetes.” said Dr. Albright. “Screening, testing and referring people at risk for type 2 diabetes to evidence-based lifestyle change programs are critical to preventing or delaying new cases of type 2 diabetes.”

Read more about this partnership and Prevent Diabetes STAT here.

Our physicians are discussing this and a myriad of clinical topics inside SERMO. If you’re an M.D. or D.O., please join us.

The post New Diabetes Prevention Initiative from AMA, CDC appeared first on Sermo.

– by Dr. Irving Loh, MD

The 2015 edition of Dietary Guidelines for Americans has not yet been finalized, but will likely give providers, patients and the food industry fits and confusion.  When the preliminary dietary outline became public and indicated that dietary cholesterol was being de-emphasized, and that eggs were off the no-fly list, a relatively high profile media commentator stated on air that he was going to toss his Lipitor™.  NOT THE SAME!

A bit of history.  Since 1980, the Dietary Guidelines for Americans has been written by the Dietary Guidelines Advisory Committee, which has been appointed by the U.S. Department of Health and Human Services and the U.S. Department of Agriculture and jointly published every five years.  Based on reviews of the literature, best evidence-based science, personal opinions of the appointed experts, and an unknown amount of industry lobbying, these guidelines are tasked to encourage a disparate American population to eat a healthy diet by encouraging the selection of foods and beverages to help us reach and maintain optimal health, weight, and prevent preventable diet impacted diseases.

Data sources include epidemiologic surveys like NHANES (National Health and Nutrition Examination Survey), National Health Interview Survey, CDC, SEARCH for Diabetes in Youth Study and data from the Alzheimer’s Association.

Not surprisingly for those of us watching the eating habits of our patients, the committee found that excess dietary sodium and saturated fat are the greatest dietary risks for all Americans over the age of 50.  In contrast, dietary fiber, vitamin D, calcium and potassium were under-consumed by Americans.  And, somewhat surprisingly, given the negative inculcation surrounding eggs since Framingham, dietary cholesterol is not considered a nutrient of concern for over-consumption.

The committee also reiterated the prior recommendations of eating more fruits, fresh vegetables, legumes, nuts and whole grains, and restricting fats and sugars.  Modest caffeine intake is now acceptable, but only if, I may add, it does not contribute to dysrhythmias or hypertension which I’m sure many of us have observed in our susceptible patients.  The panel did go a bit further than prior panels in that they suggested some policy changes to help effect their recommendations.  One such suggestion was a tax on sugary foods and beverages.  Such a tax was implemented in Berkeley, CA, but was voted down in San Francisco and New York after heavy lobbying by the beverage industry.

More prominent nutrition labeling, perhaps to emphasize added sugar content, was also a possible suggestion.  Regardless of what this committee suggests, this Congress will likely limit any recommendations that have adverse economic impact on the food and beverage industry.  The lobbyists of the American Beverage Association will see to that.

But let’s go back to the dietary cholesterol issue.  Do these proposed guidelines mean that cholesterol as a risk factor for atherothrombotic cardiovascular disease is now not an issue?  How many of our patients will now ask you about whether they need to continue their statins and other lipid lowering regimens?  Moreover, how many will discontinue their lipid therapy and not tell even tell you?

Clearly, and I mean that, CLEARLY, hyperlipidemia remains an extremely important risk factor for both primary and secondary cardiovascular prevention.  The lipids themselves, i.e., the cholesterol in LDL-cholesterol, IDL-cholesterol, VLDL-cholesterol, remnant particle cholesterol, may not be the ultimate culprit, but they are the readily measured surrogates for the protein moieties that may be the atherogenic particles that trigger the immunologic and inflammatory processes that initiate and exacerbate atherothrombosis.

The most critical factor that mitigates one’s lipoprotein values is picking one’s parents carefully.  Genetics dominantly control lipoprotein values, especially LDL-C and, perhaps less so, HDL-C.  Given that genetic “nature”, dietary “nurture” probably impacts LDL-C levels by no more than 15%.  That is not to say that extremely volatile lipid values can be demonstrated when our patients go on extreme diets (however one defines “good or bad” or “extreme”), but the important caveat here is that if the diet is isocaloric, the values may not vary all that much.  The greatest variability in lipid values occur if the patient is gaining or losing weight, not if the weight is stable.  Once the weight stabilizes, the LDL-C tends to creep back to where the genetic rheostat set it originally, correcting for slight upward creep as one ages.  Triglyceride values, and consequently HDL-C to a lesser degree, can be more permanently impacted by weight change.

Remember, all guidelines foisted upon us are really about attempts to modify behavior.  People (including we physicians) don’t really follow guidelines unless they correspond to preconceived ideas.  I’ve evolved my ideas from the perspective of having been involved with research and clinical management of lipids and cardiovascular disease for over four decades.

So, I’m actually OK with the de-emphasis on dietary cholesterol per se, but as clinicians, we need to maker sure our patient’s weight does not fluctuate, which may be associated with significant perturbations in the lipid profile.  But the lipid therapies in at-risk patients need to remain aggressively in place.

We discuss this and a myriad of clinical topics inside SERMO. If you’re an M.D. or D.O., please join us.

Bio:

Dr. Irving Kent Loh MD, FACC, FAHA (Epidemiology & Prevention), FCCP, FACP is a board certified internist and sub-specialty board certified cardiac specialist with an emphasis on preventive cardiology. He founded and directs the Ventura Heart Institute, which conducts education, research and preventive cardiovascular programs. Dr. Loh is a former Assistant Professor of Medicine at UCLA School of Medicine. He is Chief Medical Officer and Co-founder of Infermedica, an artificial intelligence company for enhancing clinical decision support for patients and healthcare providers.

The post Proposed 2015 Dietary Guidelines for Americans appeared first on Sermo.

~ by James M. Wilson V, MD

Media reports have recently focused on CDC statements indicating we are having a “severe” season of influenza. This concern was initially driven by the discovery of a vaccine mismatch involving the type A/H3N2 component of the vaccine. We have discussed this issue extensively in previous posts here on SERMO and emphasized the following points:

• The phrase “vaccine mismatch” does not guarantee a severe season of influenza. The current 2014-15 season is comparable to the activity seen in 2012-13, a non-mismatch season.
  The main exception of concern is the elderly, which will be discussed in this post.
• That vaccine mismatch associated with a dominant A/H3N2 season is common and not unexpected.

The term “severe” is imprecise. It is as imprecise as the terms pandemic, epidemic, and outbreak in today’s public health discourse. At the Ascel Bio National Infectious Disease Forecast Center, we use terms that describe the level of socio-economic disruption to a community that are captured in the Infectious Disease Impact Scale (IDIS).

Figure 1. The Infectious Disease Impact Scale (IDIS). From top to bottom, this scale is a heuristic model that describes the transition points of socio-economic disruption experienced by a community in the context of an infectious disease outbreak or epidemic.

We use the IDIS to provide a “bottom line,” high level view of infectious disease activity and are using this analytic tool to describe the effect of Ebola on the core involved countries in West Africa:

 Figure 2. Signature tracing of socio-economic disruption caused by Ebola over time in Sierra Leone. The X axis is the day, going back to the beginning of the disaster. Ebola has generated persistent IDIS Cat 6 conditions for months in Sierra Leone.

The best analogy for the IDIS is a comparison to the Fujita scale, which is a heuristic model used to describe the magnitude and potential impact of tornadoes. The IDIS is an important tool for our analysts because an “epidemic” of disease in one country may be described an “epidemic” in another- but be associated with completely different IDIS categorizations that relate to that country’s medical infrastructure and response capacity.

Currently in the United States, we have yet to document a community experiencing more than IDIS Category 2 conditions for influenza. Despite media attention, we are not observing unusual socio-economic disruption levels.

There are reasons for these observations. First, let’s take a look at the current surveillance data from this year’s influenza activity.

From a pediatric (i.e. birth to 18 years old) perspective, we are seeing a routine season of influenza in our younger birth to 4 year old children, but high activity in the 5-17 year old age group.

 Figure 3. Influenza hospitalizations in the pediatric age group. The Y axis on the left corresponds with
incidence for prior seasons except the pandemic season of 2009-10, where children were severely effected. Pandemic incidence is read on the right hand Y axis associated with the orange trend line. [Data source: CDC FluView]

Figure 4. Pediatric mortality due to influenza. This is the true bottom line for severity from a clinical perspective. We are not seeing an unusual level of mortality so far in the pediatric patient population compare to prior seasons. The main caveat is mortality data is delayed sometimes by weeks, so a final assessment at the conclusion of the season (i.e. in the summer) will be required. [Data source: CDC FluView]

 From the perspective of our working age group, which is responsible for maintaining economic throughput for the nation, this continues to be a routine influenza season.

Figure 5. Influenza hospitalizations in the working age group. In this age group, the 2009-10 pandemic season’s impact for the end of December / early January time period was comparable to a routine influenza season. This year’s influenza activity level is routine. [Data source: CDC FluView]

The elderly, however, have been hit hard by this season’s influenza, and this is the key observation for this season that has been called “severe.”

 Figure 6. Influenza hospitalizations in older adults and the elderly. In this age group, the 2009-10 pandemic season was not severe at the end of December / early January. What is notable is the 2014-15 season is associated with the highest level of hospitalizations in this age groups since before the pandemic. [Data source: CDC FluView]

 From the perspective of overall mortality due to pneumonia and influenza, this season is routine, however the data is still being compiled and will require re-examination in early summer.

Figure 7. Overall mortality due to pneumonia and influenza. So far, mortality appears to be comparable to all prior seasons of influenza. Caveat: there are inherent time delays in reporting of mortality data, so this information should be interpreted with that in mind. [Data source: CDC FluView]

In summary, we observe the following:

• The current influenza season overall is not “severe” and is comparable to the prior two years of seasonal activity. We observe no higher socio-economic disruption than IDIS Category 2 (non-crisis) conditions.
• For older adults and the elderly, this is a severe season.

One last point of importance: the concern about a “mismatched” vaccine. The majority of America, including its physicians appear to hold a belief that the vaccine is “useless” because mismatch has occurred. Yet both WHO and CDC continue to recommend the use of the vaccine. It is critical to keep in mind the following key points:

• The vaccine, while mismatched, is not fully. In other words, there remains a probability the vaccine will keep an individual out of the ICU or from dying.
• Patients should question a physician who does not offer the influenza vaccine, despite the mismatch. Physicians should offer the vaccine to patients regardless of the observation of a mismatch. If anything, observation of a “mismatch” is a major warning to society to encourage even broader vaccination than is normally done.
• Tamiflu may or may not save your life if you are hospitalized with influenza. Tamiflu is considered by the majority of physicians to be of questionable value when a patient has been ill for several days and later hospitalized. The bottom line is don’t depend on Tamiflu to save your life if you choose not to vaccinate.

Biography

Dr. James Wilson, a pediatrician and infectious disease expert with AscelBio, he is a frequent contributor to the SERMO blog.

Season flu and it’s movements in the US are discussed frequently inside SERMO.  If you’re an MD or DO please join us for the latest news shared by your peers.

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Does air pollution cause autism?

As we settle into 2015, quite a few announcements and research results are making waves this week.  Let us know which stories piqued your interest.

Autism and Pollution

A new study released this week from the Nurses Health Study II cohort looked at over 113,000 women around the issues of autism and pregnancy.  Researchers found a correlation between air pollution particulate during pregnancy, particularly during the third trimester, and children later developing autism.

3D Printing Preps Surgeons

In two separate cases, patients created 3D images to guide surgeons before the surgery took place.  A man in England printed out his kidney to help his surgeon pinpoint and remove a kidney stone.  A female patient was facing a tricky removal of a tumor above the eye.  Her husband printed and shipped a 3D image of her skull with the tumor to help surgeons prep for what turned out to be an innovative, minimally invasive procedure.  Other medical centers are catching on and we think this could be widespread soon.

Wounds Monitored by Smart Phone

Wounds don’t always heal properly.  Currently, the only way to monitor healing, is to unwrap the wounds and poke, even smell, the area for signs of infection.  Researchers at Mass General Hospital developed a “smart bandage” that is painted on the injury site and measures oxygen levels.  If oxygen levels are low, the bandage will show the area in red, indicating further medical assessment.  The best part, a doctor can check in via smart phone without needing to see the patient.

Head of Medicare/Medicaid Stepping Down

Marilyn B. Tavenner, the head of Medicare and Medicaid will be stepping down in February.  Tavenner oversaw the roll-out of the ACA including the complete botch of the federal insurance signup site.  The White House has not named a replacement.  Do you think Tavenner leaving is good for Medicare/Medicaid?

Assaults Against Doctors Common

We made the news this week when we released poll results from over 2,000 physicians.  Seventy-one percent of doctors reported being the victim of either verbal or physical assault.  The SERMOpoll sparked discussion on social media; many health care workers talked about their experiences.  How would you limit assaults on health care workers?

Physicians constantly share the latest research and medical news inside SERMO.  If you’re an M.D. or D.O., please join us; membership is free.  We are the most influential physician community in the U.S.

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credit: Associated Press

Yesterday, a 17-year-old girl received a court order to undergo chemotherapy treatments to treat Hodgkins lymphoma.  Both the girl and her mother disagree with the ruling.  The girl will remain in the hospital to ensure she receives proper treatment.

Physicians mostly side with authorities, agreeing the girl, known as Cassandra C., should receive chemo.  Survival and cure rates are quite high;  currently 83 percent of women with Hodgkins lymphoma have a 10-year survival rate.

As one oncologist inside SERMO stated, “I would treat her and let her complain to me until she is an old lady.”

A hematologist added, “Agree with those that point out Hodgkin Disease is curable, not palliable, in many if not most cases. The chemo is no treat, but not prohibitive. Mom has demonstrated her complete unfitness to provide rational care for her daughter.”

The Ethics of Forced Medical Care

Many in the media have pointed out the patient is only months away from refusing treatment when she turns 18 and question when the right to make medical decisions comes into play.  A chapter published in the book, Pediatric Critical Care Medicine, looks at when to let parents and patients decide and when the medical community should take over.   They cite specifically when emergency services are needed, and a parent is not available to give consent and when the family is unable to make an informed decision.

The teen told reporters and the state that chemotherapy will do more harm to her body than the cancer will.  Her mother also said if she gets the chemo there could be long term health affects including the inability to have children.  The Washington Post reported, “This court agrees with the trial court that, even assuming that the mature minor doctrine applies in this state, the respondents have failed to meet their burden of proving under any standard that Cassandra was a mature minor and capable of acting independently concerning her life-threatening medical condition,” Full court order here.

The ethics of forced medical care comes up fairly regularly, often for religious reasons.  One surgeon wrote, “The courts have typically sided with physicians in the case of minor children. This most commonly occurs with parents refusing surgery, or, especially with Jehovah’s Witnesses, refusing transfusions.”

What do you think, does a medical team’s knowledge trump an uninformed patient?  When is it OK for the courts to step in and mandate care?  What about forms of patient care that are so clear cut, such as parents refusing vaccinations?

There is an active discussion about this inside SERMO.  If you’re an M.D. or D.O. we invite you to join the conversation; membership is free.

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