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Thursday, February 2, 2012

Add Barrett's to the list of conditions impacted by smoking

Barrett's esophagus patients who smoke tobacco are at twice the risk of developing advanced precancerous cells and twice the risk for developing esophageal cancer, according to a new study in Gastroenterology.

Tobacco, not alcohol, was the strongest lifestyle risk factor in Barrett's esophagus patients, the lead author commented. And, the risk was higher no matter how few cigarettes were smoked per day.

Researchers collected data from 1993 to 2005 on 3,167 Barrett's esophagus patients, representing 23,692 person-years of follow-up with a mean follow-up period of 7.5 years. In the study, 117 of the patients developed dysplasia or cancers of the esophagus or stomach. Current tobacco smoking was significantly associated with an increased risk of progression (hazard ratio [HR], 2.03; 95% confidence interval, 1.29 to 3.17) compared with never smoking, and across all strata of smoking intensity.

After adjustment for confounders, there was elevated risk for former smokers (HR, 1.53; 95% CI, 0.95 to 2.45) and for current smokers (HR, 1.83; 95% CI, 1.14 to 2.92.)

The number of cigarettes smoked per day was known for just over half of smokers in this cohort, and there was no additional increase in progression risk for those who smoked more than 20 cigarettes a day compared to less than that. Pipe smokers had an increased risk of progression after adjustment for potential confounders (HR, 2.18; 95% CI, 1.10 to 4.32), but cigar smokers did not, although less than 1% of the cohort reported using cigars. Current smoking of tobacco in any format was associated with a significantly doubled risk of progression to cancer or high-grade dysplasia compared with never smokers (HR, 2.07; 95% CI, 1.34 to 3.18).

Drinking more than 10 units of alcohol per week was not associated with the risk of progression compared with those who abstained (HR, 1.04; 95% CI, 0.60 to 1.78), nor was less alcohol consumption a factor. The type of alcohol didn't matter, but the authors noted that this information was only available for 15% of the cohort.

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Wednesday, February 1, 2012

Life at Grady: First comes love

The following post, by Kimberly Manning, FACP, is adapted from her blog Reflections of a Grady Doctor and reprinted with permission. Names have been changed to protect privacy.

I saw this young couple in the residents' clinic several months ago. Super young--like not even twenty-years-old. And it was a rather odd visit to have in an Internal Medicine clinic at a public hospital. This couple was here together because even though they hadn't been using any birth control methods for several months, they hadn't yet conceived.

"So we just came to get checked out." That's what the young woman said as she looked over at her partner.

"Checked out?" I asked.

"Yeah, ma'am," he quickly answered. "Like to make sure we can have a baby."

And I looked at this teenage couple and coached myself not to have a judging facial expression. I hoped my face didn't show my thoughts.

Which included:

Say WHAT? What the hell are y'all thinking? A baby? A BABY!

But they sat there patiently--her in the chair next to the desk and him rolling around on the wheeled stool. Faces as innocent as little cherubs and eyes twinkling-twinkling like little stars.

Even though they were young, I liked how genuinely and lovingly they looked at one another.

"Do you mind me asking how old you all are?"

"Both of us nineteen," she replied. She scoldingly cut her eyes at him and he abruptly stopped rolling back and forth on the chair.

I cleared my throat. "Are you . . .like, trying to get pregnant?"

"Yes, ma'am. We're the last ones in our family. Everybody be asking what we waiting for." When he said that, he looked at her and laughed.

And honestly? This sounded completely crazy to me. Two nineteen-year-olds who'd been trying to conceive since age eighteen sitting in our clinic asking to have thyroids checked and sperms counted up to see what was keeping a bun from going into their oven.

Wait, huh?

(Click "more" below to continue reading.)

"Ma'am, do you think we gon' be here more than another hour? I got to go to work and need to know if I should call my job," he said.

His face was so boyish and the way he kept twirling from side to side on that chair made him look even younger. I couldn't imagine what kind of work he was doing.

"What kind of work do you do?" I queried.

He then told me of his job working in a storage warehouse. Good money. A very solid, substantially-more-than-minimum hourly wage. And health benefits even.

"Including dental," he added proudly.

And her? She was finishing up cosmetology school.

"It's going real good," she shared before launching into telling me about the upscale salon where she hoped to get a job.

"Yeah, she always been great with hair. She do everybody hair already so I'm glad she in school for it." He was quick to support her. It was endearing.

"That's great," I responded. Because that was great.

Great yes. Even though in my head I still thought the whole idea of two nineteen- year-olds intentionally trying to get pregnant was a little off putting. And even more, I found the thought of those same two nineteen-year-olds getting sweated by their respective families because they hadn't had a baby yet rather...crazy-ish.

That said, we ran a few simple tests on them both. Each received a full physical exam and everything checked out okay. After referring them to the family planning clinic, I bid them adieu and wished them well.

And by well I meant growing older and maturing some more before conceiving a human.

Anyway.

The other day I was standing next to the clinic elevators and who did I see? Them. Side-by-side and looking at each other just as lovingly as they had before. I glanced down at her unbuttoned coat and noticed an increasing abdominal girth poking out of the opening.

"Pregnant!" I said out loud when I saw them.

They immediately remembered me. He spoke first. "Yeah, ma'am. We just kept tryin' and we finally got pregnant!"

I love it when men refer to pregnancies as a "we" phenomenon. And you know? They were a "we." A nineteen-and-a-half-year-old we. But a "we" all the same.

I looked at their hands and their laced together fingers. Next I noticed the cursive name on his uniform. Just coming from or going to work again I supposed.

"You all having a boy?" I asked.

"Naw, it's a girl! We just fount out!" she squealed. "But everybody guessed it's a boy!"

They looked at each other again and smiled.

"She gon' be so spoiled," he said with a shake of his head. "I know it already." He glanced over at her again with her petite body with it's new miniature beachball in front. Beyond that, she didn't look pregnant at all.

"You know why they keep guessing boy, right? It's because you look so good." I figured I'd throw in my mother-wit as I mindlessly pushed the "down" elevator button repeatedly.

"Oh yeah," he chimed in, "'cause them girls rob you of your beauty right? Tha's what they say? Ha ha!"

"That's what they say." I giggled at that old adage.

"Well, not her. She been pretty since the day we start going together."

Going together. Wow.

"How long has that been?"

They both knitted their brows in tandem thinking. "Middle school," she finally answered. "Or a little before that."

We stepped onto the elevator and I watched them. He carried her purse and held up his arm for support even though she wasn't that big or tired appearing. It was just the gentlemanly thing to do for the lady you love.

And it was obvious that there was love there. Love between that young couple for sure. And no, they weren't married and yes, nineteen is hella-young if you ask me. But.

Nobody asked me. And even if they did...who am I to judge their readiness to start a family? A tax payer you say? Was this your initial thought?

Hmmm.

Funny that my initial thought was negative...or rather, it's actually not funny at all. The truth? Here I was imagining for them some life tethered to government support and generational poverty and ignorance. All because they wanted a baby at nineteen. Or was that all?

Hmmm.

Look. I sure as hell wasn't looking to have or feeling ready for a baby at nineteen. But that doesn't mean they aren't. Or that someone else isn't.

What if this hadn't been at Grady? What if this was some young ivory-faced nineteen year-old couple with tiny crosses around their necks and vermeil bands on their ring fingers?


I waved good bye to them and congratulated them once more on the pregnancy. As I watched them walk away, I froze for a moment.

Wait.

Had I passed judgment on them for being young, black and working poor? Had I sized them up and assigned them a life and a future that, in all actuality, I had no idea about at all? Had I?

Damn.

All that they had shown me up until that point was youth, yes...but more than that, just love and devotion. The same things we had when we were expecting our first baby. Harry taking off of work and holding my coat and my arm at those prenatal visits just like them. And just like our first baby and the one that came after...the main thing their little daughter would have in common with Isaiah and Zachary was that she was wanted....and conceived in love.

Young love, no less, but love all the same. I had no grounds for thinking anything else.

As they disappeared from my sight, this word popped into my head:

prejudice [prej-uh-dis]: an unfavorable opinion or feeling formed beforehand or without knowledge, thought, or reason.

I stopped at the glass door and caught my reflection...
I told that woman in the mirror, Careful, profesora....Be careful.

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Tuesday, January 31, 2012

Appropriate use criteria updated for when to revascularize

Updated appropriate use criteria guide were released Jan. 30 to guide physicians and patients when to use an invasive procedure to improve blood flow to the heart and how to choose the best procedure for each patient. Clinical scenarios affirm the role of revascularization for patients with acute coronary syndromes and significant symptoms.

Prominent among the changes are a re-evaluation of the indications for the treatment of multivessel coronary artery disease by percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) as a result of data from the SYNTAX trial, which came out after the original criteria were published.

The new criteria appear online at the Journal of the American College of Cardiology.

Among the many changes:
--PCI is changed from inappropriate to uncertain for low burden left main disease, and from uncertain to appropriate for low burden three-vessel disease. This is meant to generate careful selection of high-risk surgery patients for PCI.
--Coronary artery bypass is appropriate for patient scenarios with coronary artery disease involving two vessels to include the proximal left anterior descendent coronary artery and all variations of three-vessel and left main coronary artery disease.
--PCI is appropriate in patients with coronary artery disease in all three heart arteries only if the severity of coronary artery disease burden is low.
--It is uncertain whether PCI is appropriate in patients with three- vessel coronary artery disease and an intermediate to high disease burden.
--PCI is also deemed uncertain in patients with blockages in the left main coronary artery, alone or with blockages in other arteries and low coronary artery disease burden.
--PCI is considered inappropriate in patients with blockages in the left main coronary artery with intermediate to high disease burden

The updated appropriate use criteria, drafted in conjunction with 10 major cardiovascular and thoracic medical societies, replace a previous set published in 2009. New clinical data led to the update. For example, publication of the SYNTAX trial called for the reexamination of clinical scenarios for multi-vessel coronary artery disease.

The 2009 appropriate use criteria outlines nearly 200 clinical scenarios that reflect common heart problems seen by cardiologists. The appropriate use criteria scenarios were developed to mimic patient presentations encountered in everyday practice and to address the rational use of coronary revascularization. The ratings take into account such factors as symptoms, medication, results of stress testing, severity of disease burden, and number of coronary blockages.

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Thursday, January 26, 2012

Meaningful use core measure #13, the patient-generated clinical visit summary

One of the Meaningful Core Measures is to provide a clinical summary of the office visit to each patient. This a well-intended measure as we know that patients will often retain only a part of all the information that they received at the office visit. The summary needs to contain very important information about the visit and decisions made during the visit including patient instructions.

Patients when they leave the office often go out with a sheaf of papers and find it difficult to know which ones they really need to read.

I have been actually giving the patient the "task" of creating their own summary of the office visit. Once we have gone through the history and exam and labs, I will engage them in a discussion on next steps. Then I ask them to summarize the plans and action steps and write them down on a piece of paper. They write down what they agree to do instead of what I would tell them to do. They take this paper with them as a summary of the visit in addition to the EHR generated printed after visit summary.

This activity can take a couple minutes but is incredibly powerful. There is something about a patient's own handwritten plan that cannot be replicated by a physician generated print out.

This is a summary created by a hypothetical patient who was diagnosed with high blood pressure.

How different is it when a patient-physician discussion results in the patient writing down himself that he will cut back on the alcohol vs. a physician telling him to cut back and then handing him a printed patient instruction?

This process has another advantage. It gives the physician an idea about the patient's literacy level. This has to be addressed in a sensitive manner but is incredibly useful information that each physician should know but often does not. This may also not be appropriate for patients with writing disability (Parkinson's or rheumatoid). In these cases you can ask a patient to tell you what to write down.

If you want you can take scan the handrwitten document with an app on your iPhone or android and upload into the electronic health record (make sure your HIPAA police are OK with this. One option is not to have any patient identifiers on the image like the one above).

Neil Mehta MBBS, MS, FACP, practices internal medicine at a large tertiary care hospital in Ohio. He is also the Director of Education Technology (Academic Computing) for his medical school and in charge of his hospital system's home grown Learning and Content Management System. He is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management. This post originally appeared at Technology in (Medical) Education.

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Top 10 technologies a hospital might test this year

A top 10 list of important technologies and technology-related issues that hospital and health system leaders should pay close attention to this year questions each the need for each one based on economics, patient safety, reimbursement and regulatory pressures, as assessed by staff at the ECRI Institute.

1) Electronic health records: Hospitals will need not only IT infrastructure, but also the ability to integrate patient care device data into the electronic health record.
2) Minimally invasive bariatric surgery: Hospitals will need to develop interdisciplinary teams, invest in equipment, care setting and staffing models
3) 3D digital breast tomosynthesis: It requires more capital outlay and operational costs without a clear clinical benefit, and it doesn't replace full-field digital mammography.
4) New CT radiation reduction technologies: dose monitoring and measuring are critical to achieving lower radiation doses, and this aspect of the treatment is as important as the technology itself
5) Transcatheter heart valve implantation: hybrid cath lab models may be the ultimate destination for many of these procedures due to its lower cost and patient volumes. But this may happen only after procedures mature and proficiencies improve.
6) Robotic-assisted surgery: There's steady growth in the number and types of surgeries being done, despite a lack of definitive evidence for the superiority of it compared to traditional laparoscopic surgery.
7) New cardiac stent developments: A 60% use for off-label indications, high complication rates from treating bifurcated lesions with current stents, and higher-than-desired reocclusion and reintervention rates all signal the need for a more personalized approach to stents.
8) Ultrahigh-field-strength MRI systems: 3T systems offer better image resolution than their 1.5T counterparts, but cost about $1 million more than standard systems. Looming next: 7T systems.
9) Personalized therapeutic vaccines for cancer: The many new and high-cost pharmaceuticals and biotechnologies can cost $100,000 and more per patients, and they are all add-ons to existing therapy regimens.
10) Proton beam radiation therapy: Building these centers is a monstrous cost, as is running them. But no randomized controlled trials have proven to be more effective than photon beam treatments. And even newer (but just as expensive) regimens are also in development, carbon ions.

"Themes emerging on our 2012 list reflect ongoing impacts of healthcare reform initiatives and new technology developments that emphasize patient-centered care, including safety improvement, interconnectedness of technology, personalized medicine catering to individual care needs and preferences, and ever-increasing cost pressures," ECRI staff wrote in their white paper. "While the imperative to integrate health information technology with healthcare technology marches on, emerging devices, drugs, and procedures are tailored more than ever to individual patients' medical characteristics."

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Send comments to ACP Hospitalist staff at acphospitalist@acponline.org.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internist and ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
ACP Member Mike Aref, MD, PhD, ACP Member, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, ACP Member, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

White Coat Underground
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

ACP Internist and ACP Hospitalist also contribute to and draw upon content from Get Better Health, a network created by Val Jones, MD, to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the clinician's point of view on health care reform, science, research and patient care.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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