How primary care doctors choose the specialists to refer their patients

Dr. Kirsch, a blogging gastroenterologist lists some of the reasons why certain medical specialists are chosen:

- Reciprocity - patients are referred in both directions
- Personal relationships
- Corporate enforcement keeping consultations within the network
- Economic pressure exerted by consultants to maintain referrals. I have seen this happen.
- Specialist willingness to do tests and procedures on request
- Habit
- Patient or family request

References:
How doctors choose which specialists they refer to. KevinMD.com

Image source: OpenClipArt.org, public domain.

The Lancet: Commonest cause of maternal death is post-partum haemorrhage - one woman dies every 7 minutes

99% of all deaths in childbirth are in the least developed countries - 45 million women deliver without a skilled birth attendant every year, a situation in which the greatest number of maternal deaths occur.

The commonest single cause of maternal death is from post-partum haemorrhage, from which one woman dies every 7 minutes.


Health Technologies to Save Mothers. PATH.org video.

References:
Maternal mortality: one death every 7 min. The Lancet, Volume 375, Issue 9728, Pages 1762 - 1763, 22 May 2010.

Acupuncture Is Popular with Patients but Insurance Does Not Cover It

From the NYTimes:

Because her insurer did not cover acupuncture, Ms. Kumar had to pay for the $70 weekly treatments she hoped would put her cycle on a more normal schedule.

Acupuncture remains a largely out-of-pocket form of health care. Sessions with an acupuncturist run about $65 to $120, depending on where you live (and some leading acupuncturists charge as much as $300). Most ailments require at least three treatments, while some chronic issues like arthritis might require biweekly or monthly sessions, depending on the situation.

In a 2007 survey, 3.1 million adults reported using acupuncture in the previous 12 months, up from 2.1 million in a 2002 survey.

References:

Patient Money - Acupuncture May Help, but You’ll Need to Pay - NYTimes.com.

Acupuncture can spread serious diseases: bacterial infections, hepatitis B and C, even HIV
Does traditional Chinese medicine have a place in the health system? http://goo.gl/RH04o

Image source: Needles being inserted into a patient's skin, Wikipedia, public domain.

"Choose primary care, give up $2.5 million"

Researchers at Duke University modeled the earning potential of cardiologists and primary care physicians between the ages of 22 and 65, taking into account medical school debt, earning potential and the age at which doctors begin earning an income. They conducted similar analyses for the average b-school, physician assistant and college graduate.

Over a career, a typical cardiologist earns more than $5 million, primary care physicians earn $2.5 million and business school grads earn $1.7 million. Meanwhile, physician assistants earn about $846,000 and college graduates earn about $340,000.

References:

Choose primary care, give up $2.5M. MedCityNews.

Primary Care Doctors Make $3 Million Less Than Cardiologists Over The Course Of Their Careers. Kaiser Health News' Daily Report.

Image source: OpenClipArt.org, public domain.

What the Average American Consumes in a Year

Average size

The average American is 36.6 years old and eats 1,996.3 lbs. of food per year. The average man is 5’9” and weighs 190 lbs. The average woman is 5’4” and weighs 164 lbs.

Meat consumption

Each year, Americans eat 85.5 lbs. of fats and oils. They eat 110 lbs. of red meat, including 62.4 lbs. of beef and 46.5 lbs. of pork. They eat 16.1 lbs. of fish and shellfish and 32.7 lbs. of eggs.

Americans eat 31.4 lbs. of cheese each year and 600.5 lbs. of non-cheese dairy products. They drink 181 lbs. of beverage milks. They eat 141.6 lbs. of caloric sweeteners, including 42 lbs. of corn syrup.

Fruit and vegetables

Americans consume 56 lbs. of corn each year and eat 415.4 lbs. of vegetables. Americans eat 273.2 lbs. of fruit each year.

Coffee

Every year, Americans consume 24 lbs. of coffee, cocoa and nuts. Americans consume 0.2 lbs. of caffeine each year, about 90,700 mg.

Fast food

The foods include 29 lbs. of French fries, 23 lbs. of pizza and 24 lbs. of ice cream. Americans drink 53 gallons of soda each year, averaging about one gallon each week.

They eat an average of 2,700 calories each day.

Salt

Americans consume 2.736 lbs. of sodium, which is 47 percent more than recommended. Some pizzas are 'saltier than the sea' (NHS blog).

References:
Food Consumption in America - VisualEconomics.com.

The Stroke Robot Will See You Now - Mayo Clinic Video

Mayo Clinic — April 30, 2010 — Imagine this: you're eating dinner with your family and suddenly your left arm feels numb. Your speech is slurred. It could be a stroke, so you've got to get to the hospital fast. But what if your hospital doesn't have a stroke specialist or what if that doctor is out of town? The answer may be telemedicine. Doctors at Mayo Clinic are using a telemedicine robot that allows them to be face to face with patients who are miles away.

Are doctors required to get patient permission to use non-identifiable X-rays, CTs, EKGs for medical education online?

Sam Ko, MD, MBA asked this pertinent question on Twitter. My answer is below. Feel free to correct me and please provide references for your opinion.

Question: "Are Drs required to get Pt permission to use non-identifiable images for medical education?"

Answer: According to most journals, no.

The NEJM policy is here:

"If a photograph of an identifiable patient is used, the patient should complete and sign our Release Form for Photographs of Identifiable Patients. Any information that might identify the patient or hospital, including the date, should be removed from the image."

This is the BMJ policy:

Images – such as x rays, laparoscopic images, ultrasound images, pathology slides, or images of undistinctive parts of the body – may be used without consent so long as they are anonymised by the removal of any identifying marks and are not accompanied by text that could reveal the patient’s identity through clinical or personal detail.

Case Reports and HIPAA

Physicians must assure that the case report does not contain any of the 18 health information identifiers noted in the HIPAA regulations, unless authorization from the individual (s) has been obtained. The authorization is not required if neither of the 18 identifiers below are used in the case report.

List of 18 Identifiers:

1. Names;

2. All geographical subdivisions smaller than a State, including street address, city, county, precinct, zip code, and their equivalent geocodes, except for the initial three digits of a zip code, if according to the current publicly available data from the Bureau of the Census: (1) The geographic unit formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and (2) The initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000.

3. All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older;

4. Phone numbers;

5. Fax numbers;

6. Electronic mail addresses;

7. Social Security numbers;

8. Medical record numbers;

9. Health plan beneficiary numbers;

10. Account numbers;

11. Certificate/license numbers;

12. Vehicle identifiers and serial numbers, including license plate numbers;

13. Device identifiers and serial numbers;

14. Web Universal Resource Locators (URLs);

15. Internet Protocol (IP) address numbers;

16. Biometric identifiers, including finger and voice prints;

17. Full face photographic images and any comparable images; and

18. Any other unique identifying number, characteristic, or code (note this does not mean the unique code assigned by the investigator to code the data)

References:

Author Center - NEJM Images in Clinical Medicine.

Patient confidentiality. BMJ.

Case Reports and HIPAA Rules

The Human Research Protection Program - UCSF.edu.
HIPAA Resources - The Privacy Rule - NIH.gov.
Single Case Report Policy - Johns Hopkins Medicine.
Medical Case Report Policy - Louisville.edu.
Privacy of Individually Identifiable Health Information. Code of Federal Regulations.

Image source: Bone fracture, from Wikipedia, the free encyclopedia (public domain).

Marathon-associated ailments: “too hot,” “too cold,” “too dry,” “too wet” and “wobble and fall down”

According to the NYTimes, the most common and potentially life-threatening marathon-associated ailments are “too hot,” “too cold,” “too dry,” “too wet” and “wobble and fall down”. These translate into heat stroke, hypothermia, dehydration, low blood sodium and collapse, respectively.

The medical professionals at this year's NYC marathon had ice-water dunk tanks to treat runners who developed high fevers. Handheld i-Stat machines enabled them to analyze the chemistry of the runners’ blood, then dispense the right amounts of intravenous fluids, salts and sugar.



Understanding the Heart Hazards of Marathon Running - Video - TIME.com.

References:
Doctor Prepared for the Worst at Marathon. NYTimes.
Faces at the Finish - Interactive Feature - NYTimes.
Running With the Elites - Slide Show - NYTimes.

What's new in nephrology and hypertension

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in nephrology and hypertension:

Glomerulonephritis

In idiopathic membranous nephropathy, among patients with protein excretion less than 8 grams/day, treatment with an ACE inhibitor or ARB increased the probability of remission.

Hypertension

There was no difference in the rate of myocardial infarction, stroke or death from cardiovascular causes between the intensive versus standard hypertension therapy groups, nor in the all-cause mortality rate. ('ACCORD BP trial'). Intensive therapy included goal systolic blood pressure less than 120 mmHg, standard therapy included goal systolic blood pressure less than 140 mmHg.

Hyponatremia

Tolvaptan is a vasopressin receptor antagonists. The long-term administration of tolvaptan appears to be safe and effective among patients with chronic hyponatremia. Responses were similar in heart failure and SIADH, and more modest in cirrhosis.

Transplantation

An increased incidence of angioedema has been noted in patients administered angiotensin-converting enzyme (ACE) inhibitors plus either sirolimus or everolimus.

Autosomal dominant polycystic kidney disease (ADPKD)

Activation of the mammalian target of rapamycin (mTOR) protein may contribute to cyst growth in autosomal dominant polycystic kidney disease (ADPKD). The inhibition of mTOR with rapamycin preserved renal function and inhibits epithelial cell proliferation and fibrosis in a mouse model of ADPKD. In a human trial, cyst volume was stable on rapamycin.

The long-acting somatostatin octreotide decreased liver volume by 5% in patients with autosomal dominant polycystic liver disease.

References:
What's new in nephrology and hypertension. UpToDate.

Twitter comments:

@kidney_boy (Joel Topf): UpToDate seems to be misrepresenting the ADPKD mTOR data. See my interpretation here: More ADPKD and sirolimus data: More definitive; less encouraging

Liraglutide (Victoza) superior to sitagliptin (Januvia) for reduction of HbA1c in diabetics

Action of DPP-4 inhibitors. Note that DPP-4 normally inactivates GLP-1. DPP-4 inhibitors block DPP-4 which in turn leaves GLP-1 active. Click to enlarge the figure. Created with Gliffy.

What is Glucagon-like peptide-1 (GLP-1)?

Glucagon-like peptide-1 (GLP-1) is a GI peptide that stimulates insulin secretion (similar to sulfonylureas). GLP-1 also inhibits glucagon release, gastric emptying and food absorption. GLP-1 and another similar peptide are called incretins. As noted above, incretins have a dual action which leads to lowering blood glucose:

1. Stimulate insulin release
2. Inhibit glucagon release

Exenatide (Byetta) is a GLP-1 receptor agonist approved for adjunctive therapy for patients with DM 2 who are not well controlled on oral agents. It is available only as injections and has to be administered twice daily.

DPP-4 inhibitors, or gliptins, increase GLP-1 levels by blocking the enzyme which inactivates GLP-1. The enzyme is called DPP-4 (dipeptidyl peptidase-4). They act similarly to Byetta (see figure above) but have the big advantage to be available in oral form (pills). Gliptins used for treatment of DM2 include sitagliptin (Januvia) and vildagliptin (Galvus).

What is Liraglutide?

Liraglutide (Victoza) is a long-acting glucagon-like peptide-1 (GLP-1) analog that was developed by Novo Nordisk for the treatment of type 2 diabetes. Liraglutide has a half-life after subcutaneous injection of 11–15 hours, making it suitable for once-daily dosing (in contrast to Byetta's twice daily).


Liraglutide. Image source: Wikipedia, public domain.

Liraglutide (Victoza) superior to sitagliptin (Januvia) for reduction of HbA1c in diabetics

This Lancet study assessed the efficacy and safety of the human GLP-1 analogue liraglutide versus the DPP-4 inhibitor sitagliptin, as adjunct treatments to metformin, in individuals with type 2 diabetes who did not achieve adequate glycaemic control with metformin alone.

More than 600 participants (aged 18—80 years) with type 2 diabetes mellitus who had inadequate glycaemic control (glycosylated haemoglobin [HbA1c] 7·5—10·0%) on metformin (more than 1500 mg daily) were enrolled.

Participants were randomly allocated to receive 26 weeks' treatment with 1·2 mg or 1·8 mg subcutaneous liraglutide once daily, or 100 mg oral sitagliptin once daily.

Greater lowering of mean HbA1c (8·5% at baseline) was achieved with 1·8 mg liraglutide (−1·50%) and 1·2 mg liraglutide (−1·24%) than with sitagliptin (−0·90%).

Nausea was more common with liraglutide (27%) on 1·8 mg. Minor hypoglycaemia was recorded in about 5% of participants in each treatment group.

Liraglutide was superior to sitagliptin for reduction of HbA1c, and was well tolerated with minimum risk of hypoglycaemia. These findings support the use of liraglutide as an effective GLP-1 agent to add to metformin.

References:

Liraglutide versus sitagliptin for patients with type 2 diabetes who did not have adequate glycaemic control with metformin: a 26-week, randomised, parallel-group, open-label trial. The Lancet, Volume 375, Issue 9724, Pages 1447 - 1456, 24 April 2010.

In-flight exercises help during plane travel

Prolonged immobilization can cause circulatory stasis which is one of the predisposing factors for DVT described by Virchow in his famous triad: endothelial injury, stasis and hypercoagulability.

In a trial of previously healthy patients who traveled at least 8 hours per flight (median duration 24 hours), duplex ultrasound showed an asymptomatic DVT in 10 % of participants. In other studies, the reported risk of symptomatic DVT after flights of more than 12 hours was 0.5%. According to a 2006 Lancet study, activation of coagulation occurs in some individuals after an 8-hour flight.

This Chicago Tribune article lists some useful in-flight exercises:

In-flight exercises for beginners

- Shoulder shrugs, shoulder rolls. Ten each.
- Short sets of bending and straightening the elbows and knees.
- Walk through the plane every two hours.
- March your knees up and down in your seat.
- Lift and lower your feet on tiptoes to work the calves.

Advanced In-flight exercises

- Neck stretches; hold on each side for 15 to 20 seconds.
- If you can find space (near an exit), work the core with yoga stretches. Pigeon pose — an intermediate move of folding one leg under the body while stretching the back leg out — is an in-flight favorite of hers.
- In your seat, lift your arms over your head, grip your hands together and lean from side to side for a few seconds on each side. Repeat.
- Walk the length of the plane every hour, incorporating deep lunges. Unless you want air marshals on your case, it might be wise to notify a flight attendant.
- Put a small flight pillow in small of back to keep posture upright.

References:
Midair exercise makes for happier landings. Chicago Tribune, 10/2010.

Prolonged immobilization increases risk of DVT -- how do you define prolonged immobilization?

"Avoiding Airport Germs and Healthy Plane Travel Tips" by WebMD http://goo.gl/rLO2h

The risk of VTE (blood clots) is 3 times higher in passengers on long-distance flights than in the general population http://goo.gl/Tk45Z
Exercises for air travel — Cleveland Clinic Journal of Medicine, 2011.

Will Airplane Air Make Me Sick? No, but proximity to the other passengers very well might. WebMD, 2011.

Happiest people are 22% less likely to develop heart disease

From WebMD:

Happiest people were 22% less likely to develop heart disease over the 10 years of follow-up than people who fell in the middle of the negative-positive emotion scale.

People with the most negative emotions had the highest risk for heart disease and people who scored highest for happiness had the lowest risk.

Possible explanations for how happiness may protect the heart:

- Healthier lifestyle: Happy people tend to sleep better, eat better, smoke less, and get more exercise.
- Physiological impact: Happiness may produce a host of positive chemical changes -- such a reduction in stress hormones.
- Genetic influences: It could be that people who are predisposed to happiness are also predisposed to have fewer heart attacks.

Devote 15-20 minutes a day to doing something enjoyable and relaxing.

Strategies that could help naturally negative people become happier:

- Express gratitude on a regular basis.
- Practice being optimistic.
- Engage in frequent acts of kindness.
- Visualize one's best self.
- Savor joyful events.
- Practice forgiveness.

Regular exercise, sexual activity and good sleep are associated with increased self-reported happiness.

References:

Study: Happiness Good for the Heart. WebMD.

Experienced happiness is largely set by personality, it will temporarily respond to changing circumstances. The Lancet, 2010. http://goo.gl/ot3Kx

What's the best exercise for heart health? A combination of weight training and aerobic exercise http://goo.gl/h1YKD and bit.ly/on9sNn

Image source: OpenClipArt.org, public domain.

What's new in gastroenterology and hepatology from UpToDate

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in gastroenterology and hepatology:

Hepatitis C virus (HCV) infection

Peginterferon alfa-2a was superior to peginterferon alfa-2b with regard to virologic response rates in patients with chronic hepatitis C virus infection, genotypes 1, 2, 3, or 4. Patients being treated for chronic hepatitis C virus infection should receive peginterferon alfa-2a rather than peginterferon alfa-2b.

72 weeks of therapy with peginterferon alfa-2a plus ribavirin in patients with HCV genotype 1 or 4 was not better than 48 weeks.

Chronic use of proton pump inhibitors (PPIs)

Chronic use of proton pump inhibitors (PPIs) may lead to an increased risk of fractures. FDA recommends that healthcare professionals who prescribe proton pump inhibitors should consider whether a lower dose or shorter duration of therapy would adequately treat the patient's condition.

Ulcerative colitis

Once daily dosing of delayed-release mesalamine (Asacol 400 mg tablets) 1.6 to 2.4 g/day was as effective as twice daily dosing for maintenance of clinical remission in patients with ulcerative colitis. Remission rates were 85% in both groups.

Crohn's disease

Capsule endoscopy was not a cost-effective third test for establishing the diagnosis of Crohn's disease after a negative ileocolonoscopy and either a CT enterography or small bowel follow-through x-ray.

Azathioprine in combination with infliximab or infliximab alone had a higher rate of glucocorticoid-free clinical remission than those treated with azathioprine alone. Combination therapy and infliximab monotherapy led to significantly more complete bowel healing than azathioprine alone.

Obscure gastrointestinal bleeding

Double balloon enteroscopy (DBE) detected bleeding sources in 78% of patients with obscure gastrointestinal bleeding. Small intestinal ulcers and erosions were the most common findings.

References:
What's new in gastroenterology and hepatology. UpToDate.

Lowering Triglycerides With Exercise - Mayo Clinic Video

Mayo Clinic | October 22, 2010: Instead of taking medicine to lower triglycerides, most people can lower that number simply by moving more.

"Talk to Frank" - British government website for drug abuse prevention and treatment

Talk to Frank" is a British government-funded website for drug abuse prevention and treatment tips for the general public available at http://www.talktofrank.com

The "A to Z" list of substances explains appearance and use, effects, chances of getting hooked, health risks and the UK law. It also includes information on peer pressure, etc.