Grand Rounds 4/4/06

Grand Rounds is up for this week in form of a patient history.

... and who said medical blogs were dwindling?

Medicine, Upside-Down

Sorry about the extended hiatus over the past few weeks - had a bit of excitement going on and couldn't find the time to post. Barely, MD will try his best to be a little more regular in the future (maybe some prune juice is in order?)

Anyhow, that past few weeks have been huge in terms of large cohort studies. At least three major epidemiological findings rattled the medical community and changes to treatment guidelines are likely to affect almost every patient in the developed world.

Vitamin D and Calcium - A gargantuan study involving 36,282 women between the ages of 50 and 79 sought to determine whether supplementation with vitamin D and calcium correlated with a reduced risk of bone fracture. After decades of expounding on the benefits of these two supplements in post-menopausal women, it seems the data are less enthusiastic than the medical community has been. The study concluded that:

Among healthy postmenopausal women, calcium with vitamin D supplementation resulted in a small but significant improvement in hip bone density, did not significantly reduce hip fracture, and increased the risk of kidney stones.

The authors of the study won't go so far as to recommend a change in treatment guidelines, but far be it for this blog to ignore such compelling data. Given that Americans spend hundreds of millions of dollars to supplement their diets with calcium and vitamin D, it might be time to re-evaluate this excess and see if that money might be put to better use elsewhere... say, perhaps, in gym memberships.

Glucosamine and Chrondroitin - As if the vitamin D bombshell weren't enough to rattle aging Americans and their blind trust of the medicine cabinet, a second study was sure affect the supplement landscape. Glucosamine and chrondroitin have long been used to treat osteoarthritis under the belief that these two molecules are essential structural components of the joints. The working hypothesis was that worn-down joints in osteoarthritis sufferers could be restored by supplementation with the exact components that appear to have been degraded. To study the efficacy of these two supplements, researchers recruited 1583 patients with symptomatic knee pain resulting from arthritis and followed progress of their symptoms. Again, the double-blind placebo controlled trial prevailed:

Overall, glucosamine and chondroitin sulfate were not significantly better than placebo in reducing knee pain by 20 percent. As compared with the rate of response to placebo (60.1 percent), the rate of response to glucosamine was 3.9 percentage points higher (P=0.30), the rate of response to chondroitin sulfate was 5.3 percentage points higher (P=0.17), and the rate of response to combined treatment was 6.5 percentage points higher (P=0.09)...

Glucosamine and chondroitin sulfate alone or in combination did not reduce pain effectively in the overall group of patients with osteoarthritis of the knee.

This study may have revealed that Americans have been spending inordinate amounts on molecules that have little to no activity in the body:

Osteoarthritis is the most common form of arthritis in the United States and has a major effect on the health-related quality of life. In 2004, the estimated direct and indirect medical costs associated with all forms of arthritis exceeded $86 billion. Glucosamine and chondroitin sulfate are the most widely used dietary supplements for osteoarthritis, with estimated sales in 2004 approaching $730 million.

Moreover, the authors also gave us some clues as to why glucosamine and chondroitin may be not be functioning as previously believed. It seems that these two molecules are not terribly stable and after passing through the digestive system, not much is left of either to reach the joints. So despite the results of this trial, maybe our friends in pharma can find a novel way to protect these compounds from being degraded in the GI tract.

Third Party Prayer - "Prayer? What does prayer have to do with cold, hard data?" you might be wondering. Well, in a science that used to subject people to mustard gas and blistering hot instruments for the 'rebalancing of the humors', no health intervention can remain unexamined. The American Heart Journal just reported that having a third-party pray for a patient has absolutely no effect on patient outcome. Complete with its own major-drug-trial-acronym, STEP, the Study of the Therapeutic Effects of Intercessory Prayer (should it be STEIP?) concluded not only that prayer doesn't improve outcome, but that the knowledge of someone praying for you may actually increase the likelihood of complications... yikes!

Intercessory prayer itself had no effect on complication-free recovery from CABG, but certainty of receiving intercessory prayer was associated with a higher incidence of complications.

I can't say for certain that this study really tells us anything about anything. What conclusions can we draw? Do we tell families not to pray for loved ones going into surgery? Do we stop believing in the supernatural because hey, if well-controlled, experimental prayer increases complications just think what actual religiosity might do! Or do we go about our existence, content in the knowledge that we do what we can and believe in what we trust? I for one am thoroughly confused by this trial and am not entirely certain what these researchers set out to prove. Were the results overwhelmingly in favour of prayer, or overwhelmingly against prayer, would anything really change?

Next time, let's have a study on how many patients we could have saved using the resources that STEP just wasted.

Grand Rounds 3/08/06

Grand rounds is graciously being hosted this week by Emergiblog.

Check it out - the best of the medical blogosphere.

Of Flipped Cars and Brain Bleeds

If EMS has taught me anything it's that appearances can often be deceiving.

On this particular Monday morning, I happened to be covering for a friend who decided it was a good day to skip town and go camping. Around 9am we got a call for a motor-vehicle accident (MVA) with one patient.

Alright, fair enough.

We take the local highway to get to the scene, and along the way, we meet up with three police cars, two rescue trucks and a fire truck. Hmm... interesting - this much attention for an ordinary car accident?

Our entourage of seven emergency vehicles is barreling down the highway much faster than it should be (typical guys, we like to show off our engines). And the sound of all our sirens must be deafening, as pedestrians on the sidewalk visibly cringe in pain when we pass. Finally, after twenty minutes of concocting all sorts of interesting theories about this call, we see the scene and gasp.

When you approach an overturned car sitting in the middle of the road a few things start going through your mind, not the least of which is how you can safely stage the ambulance on a major roadway. The real problem will be getting this patient out of the car (extricated) because he will obviously be stuck (entrapped) in an awkward position. His spine has also likely taken quite the jolt so it is imperative to keep him straight and move him gently lest our movements sever the chord and paralyze him. So my partner and I unload all of the rescue equipment and rush over to the car ready to provide life support and extricate this victim.

We anxiously approach the car and look inside, afraid of what we might find - and hey, there's nobody in there. A heavy-set man comes up behind us and is furious, "I'm not paying for a trip to the hospital. Go home! Let me sort this out with the police."

Needless to say, I was absolutely shocked: "Sir - you just crawled out of an overturned car on a major highway. You could be bleeding in any number of places, your brain could have been bruised, bones could have broken and, frankly, you could drop dead at any second!"

This was one stubborn dude. He cursed and yelled and swore until he was red in the face. Not only did he wreck his car, but now he'd have to pay for medical treatment.

Poor guy.

After nearly 20 minutes of begging him to come to the hospital, he finally relented and we put him in a collar, backboarded him and took off driving faster than when we had arrived. There were no symptoms or signs on scene. The patient felt completely fine, complaining of no pain at all. When we started transporting, however, things got a little shady.

A minor headache turned into nausea, which became difficulty breathing, which finally escalated to loss of consciousness (LOC) just as we entered the emergency department.

As it turns out, this gentleman, who at first refused to be transported, had a major subdural bleed (bleeding in the brain) and had fractured several vertebrae.

To be sure, when I said he could have died on the spot, 'twas not hyperbole.

Book Review: The Great Influenza

John Barry's The Great Influenza chronicles the violent upheaval of American medicine that occurred around the time of the 1918 influenza pandemic. The book does an excellent job of introducing how modern medicine had truly yet to emerge as a means of treating the ill. Patients would routinely undergo blood-letting, and doctors frequently prescribed irritants that caused boils and cysts to form - all the in the name of re-balancing the "humours" whose disequilibrium was causing disease.

Indeed, the turn of the century was not that long after Darwin proposed the theory of evolution, and the Germ Theory of Disease was still a cotentious issue. For those seeking a good grounding in the history of medicine, or specifically, in how America came to be part of the scientific revolution that gave birth to modern medicine, Barry has done an excellent job in this text.

A remarkable history has been compiled here, combining the intricate politics, bureaucracy and history that established America's medical schools, along with clear and succint explanations regarding the epidemiology and pathology of the influenza virus. Specifically, this history is written as a story in which the protagonists emerge initially with too few tools and without the institutional support necessary to attack a global health threat.

As the story progresses, the heroes believe they have found the cause of influenza to be a bacteria that seems ubiquitous in infected patients. By the time science discovered that influenza was caused by a virus however, the pandemic was over and the death toll had already reached millions.

Truth be told, we still know relatively little about the influenza that caused the 1918 pandemic and are not much better equipped to handle it than we were 100 years ago. Hence the concern over our H5N1 friend.

Scientific Humanities

Dr. Campo of the Beth Israel in Boston wrote a reflective piece in JAMA last week concerning the dehumanization of medicine.

... here we were, scientists and artists from across the globe, all deeply concerned about the growing dehumanization of medical care, yet quite unsure about under which inspiring banner, exactly, we might most effectively unite to combat it. "So, what are the medical humanities, anyway?" asked a savvy medical student during a break as we nibbled on cookies, neatly summing up the vast yet unspoken problem we had posed to ourselves from the outset.

The student clearly hit on an issue that many recognize, but few are equipped to address. Combining a humanistic approach with the cold, hard science that has proven statistical outcomes to back it up just seems a contradiction of terms.

My initial reaction to his question enacts the very difficulty of even attempting to conjure up such a definition. On the one hand pour in all the emotions of knowing intuitively that the way medicine is now taught and practiced is simply wrong, that the humane is being supplanted by unfeeling science and uncaring economics—the incalculable distress I feel when I hear an intern refer to her patient as "the breast cancer in room 718," the ephemeral sadness in cutting short a visit before we can delve into my patient’s grief at the loss of her husband because I have three others waiting...

So knowing that the the physician-patient relationship is headed for ruin, what are we going to do about it? In my experience, the most useful practice has been to simply pause the assessment algorithm for a moment and consider what the patient is going through.

Whether it be on the ambulance, in the waiting room, or on the operating table - consider yourself in the patient's position and try to empathize with the fear, anger and anxiety that patients regularly feel. Sure, you may be rushing to get through a procedure or you may even be scared yourself if the patient presents with something serious that you may not think you can handle, but stopping for a moment to think is the best thing you can do for both patient and yourself.

Great words were once uttered by a physician who made humanistic medicine his calling: "If you treat the disease, you win some and you lose some. But if you treat the patient, I guarantee you'll win every time."

The High Cost of Healthcare

The delivery of health care in America needs help. Following none of the rules that govern supply and demand, deviating from every conceivable market predictor, and continually swallowing more of the national GDP, the medical system is acutely ill. The figure most often cited in raising this issue is that medical spending in America now accounts for 16% of the national GDP ($1.7 trillion). By comparison, the next-highest spending country is Switzerland, which spends 10.9% of its GDP on medical care.

So why the disparity?

Though there are numerous answers to this question, none is being adequately addressed - medical spending is projected to reach 20% of GDP within a decade. That means 1 of every 5 dollars spent in the US will be going towards some form of health care. The medical community may see that this bodes well for the future of the profession, but in actuality, most of this money is leaking out of the system into overhead costs such as insurance administration, patient record-keeping, political lobbying, and of course, malpractice settlements/fees/insurance.

Among the most surprising questions raised by the American system is how privatized medicine came to be more expensive than the single-payer, socialized system found in most of the developed world. By all measures, Americans enjoy neither the highest quality of life, nor the longest lifespan despite their unquenchable spending habits. Some argue that high costs are a natural result of the unequalled rate of innovation in the US. This camp contends that American companies spend more on research and development than other countries. The resulting drugs and medical products are then exported for a fraction of what they cost to develop, and voila - foreign nations enjoy the medical benefits of American innovation without the hassle of years-long investment costs.

Another compounding factor is how much is spent on end-of-life care. It is well known that one percent of the population accounts for thirty percent of health spending in the United States. Meanwhile, a third of Medicare's budget is spent on patients in their last one year of life. It seems that other countries may have learned to embrace the end of life as a natural event, not be fended off tooth-and-nail in the face of all that medical science has say. Certainly, patients should have the option to pursue aggressive treatment, but it is the physicians' role to prevent cases of gross misjudgement from allowing to proceed.

There are 45 million uninsured Americans who sit at the brink because the system cannot afford to support them. Perhaps a re-allocation of resources is in order.

... and of course, there will always be malpractice to keep physicians' costs high and others' pockets well-lined.

Oncology and the Decline of Childhood

The other day I learned what childhood is all about. Or at least, what it's supposed to be about.

To introduce this case, I should tell you that my spare time is spent working as an Emergency Medical Technician. The work gives me a refreshing view of the medicine that rarely makes it through hospital doors and that few professionals get to see. This is the dirty medicine; the medicine that involves rushing into someone's bedroom to find them clutching their chest; the medicine that involves climbing into car wrecks and choosing between driver and passenger; the medicine that too-often makes one wonder how the world ever became like this.

But this call was nothing like that. This call was more about humanity than it was about medicine and that's why it is so memorable.

Around 11.30pm we were dispatched for a 6 year old complaining of "acute pain." We arrived on scene to find Emma (sorry, not her real name) curled up in her parents' bed screaming in pain at the top of her lungs. She was apparently a non-Hodgkin lymphoma patient who had undergone such torturous treatment that it gave rise to neuropathies and chronic uncontrollable pain.

Well, Emma clearly needed to go to the hospital, but any time somebody touched her the pain would get worse. By now she had been screaming for so long that her lips were beginning to turn blue and her face was pale. This was not your ordinary tantrum. So we made a decision. Emma's mother scooped her up, put her on our stretcher and out we went.

The amazing thing about kids is how quickly they go from incomprehensible misery to complete indifference. Once we got into the ambulance I guess there were enough distractions that Emma stopped crying and just starting pressing all the buttons, undoing all the buckles, opening all the cabinets, and generally making a mess of the place. To say the least, we were relieved that the colour was now coming back to her face.

Normally, our patients go to the local hospital that's no more than 5 minutes from anywhere in town (yes, small town). The short transport means that EMTs rarely get to know their patients very well before the trip is over. Pediatric oncology cases, however, get driven to an academic center that's thirty minutes away (even when driving with lights and sirens) so Emma got to tell me her whole life story before it was time to say goodbye.

Diagnosed with her lymphoma almost immediately after birth, Emma was forced to endure the oscillating success and failures that all oncology patients experience. The cancer is in remission. Uh oh, it relapsed. Remission again. Relapse once more. The emotional trauma is distressing enough for an adult, let alone a child who hasn't a clue what life is like without chemotherapy.

Emma told us all about her ordeals - about how she can't play with other children because her "immune system is broken" and about why she can't go to the local hospital because only "special doctors can fix a special girl."

As it turns out, her birthday was just the week before, but she didn't have a birthday party. "Remember?" she asked, "I can't play with the other kids because I'm neu- neu- neut- neutropenic." And there it was. This six year old was going through unspeakable pain, enduring a suffering that nobody should ever have to conceive, and in the back of a speeding ambulance she saw the puzzled look on the EMT's faces and began to explain what neutropenia was.

No sooner was she done with her explanation than she asked specifically for an "N-95 NIOSH approved mask" to "keep the germs away." My partner put the mask over Emma's face and immediately observed that it looked like a duck-bill. And so, for the rest of our ride to the hospital, the wail of the sirens was drowned out by Emma's going "quack, quack, quack." Perhaps she was child after all.

Now, when I think back, I have trouble remembering how Emma explained neutropenia. All I can picture is a duck.

The Continued Woes of Medicare Part D

Despite having overcome the confusing maze that is Medicare Part D, many seniors still find themselves trapped in a bureaucratic netherworld. On 1 January 2006, all medicare beneficiaries who had not signed up were automatically assigned to a random drug plan. Those who later chose to switch to a plan of their choosing are finding themselves enrolled with two plans - paying two premiums, two deductibles, two co-pays, and sometimes, getting half the coverage. The New York Times reports:

"Numerous beneficiaries have switched plans," the memorandum said. "Our processing systems have not always sent the enrollment and disenrollment information to the appropriate plans." As a result, it said, "many (possibly all) of the beneficiaries who switched plans are active on enrollment files at multiple plans."

Here's hoping this gets sorted out soon.

(Check out Graham's excellent coverage of how the Medicare saga has unfolded.)

Premature Birth and Journalism

The Journal of the American Medical Assocation (JAMA) published an interesting article on the outcomes of babies born prematurely. The study looked at 149 extremely low birth weight (ELBW) babies and compared them to 133 normal birth weight (NBW) babies born between 1977 and 1982. Unfortunately, the study does not discuss the gestational age of the participants at delivery, so it is important to keep in mind that two decades ago, the limits of viability were much later (today's neonatal intensive care units can care for babies born at 22-weeks of gestation. Twenty years ago these neonates would not have been viable).

The study sought to compare the transition to adulthood of ELBW and NBW babies, as defined by completion of a formal education and successful employment. Given the high prevalence of neurological deficit among babies born at low birth weight, the authors hypothesized that the ELBW group should attain lower levels of achievement than the NBW group later in life. Surprisingly, the author's conclude:

Conclusion: Our study results indicate that a significant majority of former ELBW infants have overcome their earlier difficulties to become functional young adults.

Interestingly, the rest of the paper is riddled with data that suggest otherwise:

In a subanalysis, a higher proportion of ELBW young adults were neither employed nor in school (39 [26%] vs 20 [15%] ...However, some differences in markers of academic achievement were lower in ELBW young adults, such as a lower proportion with advanced high school certificate and university enrollment or graduation. As in other studies,^{23, 27} VLBW male participants did less well academically than VLBW female particpants. A small proportion ( supervised employment in sheltered workshops and were living in group homes.

Now, I applaud the authors in concluding that ELBW and VLBW babies certainly do grow up to lead meaningful and productive lives, but the fact cannot be ignored that a significant proportion suffers from debilitating morbidity, and a good deal do not survive to be discharged from the hospital after delivery.

A month after publication, the New York Times picked up this story and summarized it without careful scrutiny of the data. The way this article reads, the complications of prematurity have become a thing of the past and mothers giving birth to low-birth-weight babies should have little concern. Sadly, the rates of morbidity among premature neonates remains incredible high for babies born as late as the 28th week of gestation and this gives rise to numerous ethical issues that trouble both parents and physicians alike.

Among the most daunting issues are what to do when a parent seeks to withhold treatment from a baby that has a high likelihood for developing neurological complications. Different states approach this question from various angles, but as a general rule, the physician is compelled to act in accord with his/her ethical beliefs. Compiling the guiding principles of the law, an understanding of medical knowledge, the parents' wishes and physician's own beliefs into a coherent and acceptable plan of action has proven to be very murky ground for many a doctor.

To be sure, however, the availability of accurate information should help parents and physicians alike make decisions that each believes to be fair and ethical - articles that overstate the case, such as the two cited in this entry will do little to alleviate confusion at the bedside.

(See Kevin, MD's blog for other examples of publication mishaps.)

Avian Flu (H5N1) and Why We Care

Long before the mainstream news media began spinning the impending bird flu pandemic into a veritable colloquialism, the H5N1 strain of influenza virus was already preparing to make its debut. The virus that has captured the attention of public health organizations the world over is nothing more than an altered strain of the virus that gives millions of people the flu each winter. Let us go even further and say that by altered, we mean evolved (those harbouring doubts about evolution and Darwinism have ample opportunity to voice their concerns in the comments below).

One of the main reasons that exposure to the common flu does not cause violent reactions is that, as a population, we have all been exposed to various antigenic components of the virus at different points in our lives. The human immune system retains the ability to recognize each of these components individually, such that when they re-assort to create new viruses, there is at least a partial defense in place that can hinder viral replication. The H5N1 strain on the other hand, is an agglomeration of the most highly virulent genes found in influenza, coupled with novel antigens that humans have not seen since about four decades ago (yes, this means that those older than forty were likely exposed to a related strain and might exhibit some natural resistance should a pandemic occur). Fortunately, the virus is only capable of infecting avian species at present, such that humans are momentarily safe. The problem is that viruses are prone to incredibly rapid evolution. The machinery that replicates the virus DNA is very prone to making errors, and so, each new generation of viruses has changes to its genetic code that were not present in the “parent” generation. Though most of these mutations are lethal and produce viruses that simply degrade without ever infecting anything, some of these novel “offspring” gain advantages over their parents. The ability to infect human beings might be viewed as one such advantage.

Given enough opportunities to come into contact with humans, the H5N1 strain of the influenza virus is certain to make the leap from birds to humans – it is a matter of simple probability. Alternatively, if an intermediate animal, such as a pig, is infected by both the bird flu and a human flu simultaneously, the genetics is such that the genes can re-assort (mix together) and create a new virus that is part bird flu, part human flu. Therein lies the true danger, for if H5N1 were to reassort and acquire genes that facilitate human infection, the disease would spread on a scale previously unknown in history. With the dense populations and inter-continental transportation systems available today, one new virus particle in Asia need only infect a single farmer to become a worldwide pandemic.

And so, governments have resorted to culling bird flocks in an attempt to reduce the virus population. By reducing this viral reservoir, people hope to diminish the opportunities that virus has to reproduce and try out new gene combinations. Although a valiant effort, it would be virtually impossible to exterminate a virus that has already made its way across three continents. Culling the animals in an attempt to hamper infection is no substitute for the effective study of possible drug targets and vaccine development.

Hello Medicare Part D

The introduction of Medicare Part D two months ago brought with it a good deal of confusion and apprehension, as many seniors covered by Medicare were told that they no longer had drug coverage. Though the legislation was intended to provide seniors with an already convoluted form of catastrophic health insurance, initial administrative errors prevented enrollees from picking up drugs that would have been easily acquired the day before. Fortunately, the states themselves stepped in on this one, shelling out millions to cover their citizens until the federal government can sort out this mess.

For those unfamiliar with this legislation, this government website tries to explain the basics. Keep in mind that this program was intended for seniors taking numerous medications - so if you find the plans confusing, just imagine what the actual enrollees are going through.

Essentially, Medicare Part D was designed to provide "catastrophic coverage." That is, it will do little to help those who spend only a few thousand dollars per year on drugs, but should greatly reduce the burden on those who find themselves spending in excess of $5,100 per year on medication. Without going into too much detail, here's basically how it works:

• There is a $250 deductible (patient pays initial $250).


• Between $250 and $2,250, Medicare covers 25% ($500 of coverage).


• Between $2,250 and $5,100, patient pays 100% (the "donut-hole" - Medicare does not assist with this $2,850 segment).


• Beyond $5,100 the "catastrophic coverage" kicks in and 95% of costs are covered by Medicare ad infinitum.
  

To summarize - patients spending exactly $5,100 receive only $500 assistance from Medicare. However, say a patient spends $100,000 on drugs per year, he/she will only have to pay $9,345 and the rest is covered by Medicare. Makes sense?

Among the problems with the whole concept of Part D is that it was designed primarily by big pharma (the pharmaceutical industry and its lucratively-compensated lobbyists). In socialized healthcare systems, such as those of Canada and England, drugs are purchased under a single-payer system ( a so-called monopsony). As the only buyer of drugs in these countries, the federal government is in a position to negotiate substantial discounts with pharmaceutical firms. Seeking entrance into a national market is certainly something that drug companies are willing pay for, and it is these single payer systems that ensure the savings carry over to the consumer.

In the United States, however, the industry pressured legislators to bar such monopsonistic negotiations on the part of the federal government, and thus, no savings were incurred. In fact, given that millions were randomly assigned to drug coverage plans, Part D has actually caused the prices of certain drugs to rise.

Unlike other markets where changes in price are directly felt by the consumer and producer alike, the healthcare field suffers from an excruciating disconnect. Pharmaceutical firms have no standardized strategy for pricing their products because ultimately, the patient will feel little to none of the actual cost. By paying high premiums, deductibles and co-pays, the American public has been lulled into a state of relative ignorance regarding how expensive drugs actually are. As a consequence, insurance costs have been steadily rising and more people than ever are now without insurance (~45 million Americans, at last count).

More on the maddening nature of American healthcare later.