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Healthcare Updates

Links and commentary to healthcare news around the internet

A New "Silent Killer"?

Hypertension has often been dubbed the “silent killer” because most people don’t feel any different when their blood pressure is elevated, yet longstanding hypertension has adverse effects on so many organ systems – heart, brain, eyes, kidneys, etc – that it will eventually kill the patient if the hypertension is left untreated. A study out this month in the journal “Gastroenterology” shows that there may be a new “silent killer” on the block. The authors analyzed blood samples from 9100 adults at the Warren Air Force Base collected between 1948 and 1954, looking for serum markers of celiac disease. They then compared the rates of undiagnosed celiac disease with recent blood samples from patients in a Minnesota town. The study had two surprising conclusions. First, the incidence of celiac disease in patients 60 years ago was 0.2% while the incidence of celiac disease in the current blood samples was 0.8% to 0.9%. I wasn’t able to access the whole study on the Gastroenterology web site, but other confounding factors such as sampling bias may have explained at least some of these differences. Second, patients with undiagnosed celiac disease had a nearly 4-fold increase in risk of death during the 45 year follow up period. Again, correlation does not necessarily mean causation, so it would be interesting to see the causes of death in the study population. Untreated celiac disease is associated with an increased incidence of lymphomas, thyroid disease, and gastrointestinal cancers, so an increase in death from those diseases in the study population would be more impressive than a bunch of deaths from car accidents or drug overdoses. Celiac disease was featured in an episode of “House” and has affected Elisabeth Hasselbeck from “The View”. Will have to go to the medical library and pull the article to read through it further, but just found the conclusions surprising.

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Repost: Let The Mayhem Begin

I rarely do re-posts, but each time the new round of residents shows up in their brand new lab coats, it makes me think of this story. Today I was grinning on the inside yet again. —– Medical studies prove it. Interns are more error prone during the first month of their first year in training. July 1 is the “changing of the guard,” so doctors and patients alike – be careful out there. In honor of the graduating students and the residents graduating to their new PGY year, below is my version of a MasterCard commercial for the best story I heard about a new resident on an OB service. First a bit of an explanation. When a woman is in labor, doctors will periodically do a gyne exam to determine how dilated the cervix has become. When the cervix is only 1 or 2 cm dilated (sometimes called “fingertip” dilated because all you can get in there is a fingertip), delivery usually isn’t imminent. As the cervix dilates, you can begin to feel the baby’s head (unless there is a breech presentation and you feel a foot or the baby’s buttocks). When the patient hits 8 or 9 cm, the patient usually starts feeling a need to push the baby out. Grab your catcher’s mitt, because the baby is coming. A little more information about cervical dilation in pregnancy is here. Getting back to the story … mind you that this story is hearsay, but it comes from a friend of mine who worked as a secretary on an OB floor, so I consider her a pretty reliable source. I also did an internet search to make sure that I’m not perpetuating some urban legend and I couldn’t find anything. So here goes: Medical school education: $240,000 Brand new white lab jacket with embroidered name: $37.50 Four pack of Red Bull to keep you up all night during your first call: $9.00 Obstetrical textbook to learn about the stages of labor: $219 Three one-minute cell phone calls to the chief resident to update him on the patient who is pushing but whose cervix remains “fingertip” dilated: $1.20 Spanish-English dictionary to find out why the patient keeps saying something sounding like “debo empujar” (”I have to push”) and keeps calling you “pendejo“: $16.95 Watching the OB nurse double check the patient’s cervix, flip out, and call for a STAT c-section because the patient’s cervix is fully dilated, the newborn is in a breech presentation, and you’ve been sticking your finger in the kid’s anus instead of the mom’s cervix for the past 30 minutes: priceless

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Health Care Political Cartoon

Can’t link directly to the cartoon, so am posting a low-res image below and you can go to cartoonist RJ Matson’s site to find the full-sized version. Both insightful and sad at the same time – and likely a reason that any government-run system will not be an improvement on the current system.

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Think You Have Appendicitis? Here, Pee In This.

A promising new test for appendicitis involves only a patient’s urine sample. In an Annals of Internal Medicine article published June 23, 2009 (still not online at this time), researchers at Children’s Hospital in Boston have found that the body excretes many proteins during acute inflammation of the appendix. The protein that was found to be most consistently present in acute appendicitis cases is called leucine-rich alpha-2-glycoprotein, or “LRG” for short. According to the Time article, the protein is specific to immune cells in the appendix, and LRG testing has “statistically negligible rates of false results,” meaning that it was very good at separating those who had appendicitis from those who did not. Unfortunately, the test has only been validated in children thus far, so more testing is necessary to see whether the test can be validated in adults. The implications of this test are huge. Appendicitis is one of the more difficult diagnoses to make clinically and missed appendicitis is an often-litigated issue, prompting many physicians to order expensive CT scanning in anyone with right lower quadrant pain. As many as 30% of appendectomies end up showing no appendicitis. If LRG testing has a low false positive rate (i.e. test is positive when there is no appendicitis) and a low false negative rate (i.e. test is negative when appendicitis is really present), it would save a lot of unnecessary surgeries, would decrease the number of CT scans being performed, and would significantly reduce the transit times in ED patients who have lower abdominal pain. Unfortunately, as GruntDoc often says, “the devil is in the details.” I suspect that other inflammatory conditions of the bowel such as diverticulitis, colitis, and even gastroenteritis will also cause extra amounts of the protein to be secreted, causing “false positive” tests. My guess is that LRG testing will be similar to D-dimer testing for pulmonary emboli in the future – useful to exclude appendicitis if it is “normal” but requiring more testing to definitively pin down a case of appendicitis in an adult if it is positive. Nevertheless, this could be one more bullet in a physician’s diagnostic arsenal that will hopefully improve patient care. I just hope it doesn’t become one of those things that gets ordered as part of a battery of tests on an abdominal pain patient while docs just do a CT scan anyway. Kudos to the researchers at Children’s Hospital in Boston for thinking outside the box on this one.

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Promises Promises …

Very poignant article in Yahoo news about how the federal government is failing to meet the needs of many patients in the Indian Health Services – and the disastrous effects the broken promises are having. A five year old with stomach pain who stopped eating who visited the clinic ten times and was diagnosed with “depression.” Later the family discovered she had terminal cancer. She died at age six. Another patient was given cough syrup for his congestive heart failure and sustained damage to his heart. He died while waiting for a transplant. Another patient visited the clinic with stomach pains for 4 years and was diagnosed with possible tapeworms and stress. Later, she discovered she had metastatic cancer. Yet another patient couldn’t get a prescription filled despite repeated trips to a clinic because of lack of appointments. She died before she was able to see the doctor. Few doctors are willing to work in remote reservations, there is a lack of funding (some reservations warn “don’t get sick after June,” when the federal dollars run out), and care is rationed. In fact, one third more funding is provided for the health care of felons in federal prison than is provided for American Indians on reservations. Then read this Yahoo news story about the massive budget cuts that are coming down the pike in the healthcare reform package. Not too hard to connect the dots.

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Two Thoughts on Health Reform

I don’t always agree with Uwe Reinhardt’s insights into the health care system, but he is so incredibly spot on with this quote that I had to post it. [Countries with functional socialized systems] all mandate the individual to be insured for a basic package of health care benefits. Many Americans oppose such a mandate as an infringement of their personal rights, all the while believing that they have a perfect right to highly expensive, critically needed health care, even when they cannot pay for it. This immature, asocial mentality is rare in the rest of the world. An insurance sector that must insure all comers at premiums that are not contingent on the insured’s health status — a feature President Obama has promised — cannot function for long if people can go without insurance when they are healthy, but are entitled to premiums unrelated to their health status when they fall ill. A central concept of medical systems in many other countries is “social solidarity,” not irrational demand for the best medical care someone else can pay for. The US is going to have to emulate another functioning system if it is going to survive. The German model deserves some consideration. —— In addition, Alexander sent me a link to an Investor’s Business Daily editorial about how Oregon is working on health care reform. Oregon has compiled a list of 680 treatments for medical conditions and has ranked them in order of importance. Oregon will only pay for the top 503 on the list. Treatment for everything below number 503 must be paid out of pocket. Patients with broken toes, cracked ribs, and liver cancer are out of luck – they’re all ranked below number 503. However, treatments for obesity, schizophrenia, pathologic gambling and sexually transmitted diseases are fully covered. I foresee such a system as a way that health care spending will eventually be curtailed in this country. Liver cancer isn’t covered because not a lot of patients get liver cancer. Therefore, their collective voices are relatively small. When treatment is expensive and relatively few patients are affected, the treatments will be cut. Collectively, patients will receive more care for less expensive conditions that affect more people, but to keep things budget-neutral, patients who have less common diseases will receive less care. Even though Oregon admits that malignant neoplasms are a leading cause of death in anyone 11 years old and older (report pages PT4-PT11), it won’t pay for the care of “ill-defined malignant neoplasms” (#612). Doesn’t say anything about “well-defined” neoplasms, either. Refusing to pay for treatment of malignant neoplasms is great for saving money, but it is essentially a death sentence if you develop an ill-defined malignant neoplasm. Just hope to God that any neoplasm you get is benign. Those are still covered … unless you have a benign neoplasm of the eyelid (#516), kidney (#529), nasal cavities (#539), bone (#540), genital organs (#577 and 603), breast (#638), skin (#646), or digestive system (#656) – then you’re still SOL. Also note how many of the things that will not be reimbursed are conditions with “no or minimally effective treatments or no treatment necessary.” Who determines whether a treatment is “minimally effective”? Why the same entities that pay for the treatments, of course: U.S. to Compare Medical Treatments It’s the Golden Rule: He who has the gold makes the rules.

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