Knee Surgery Ineffective for Many Cases of Torn Cartilage

A normal knee X ray. Credit: Wikimedia Commons
A normal knee X ray. Credit: Wikimedia Commons

With minor variation, the following is an extremely common sequence of events. A man notices slowly worsening nagging knee pain that persists over months. He sees an orthopedist who examines him and orders an MRI. The MRI shows a tear in the medial meniscus. (The lateral and medial menisci are the cartilage pads that cushion the knee joint.) Pain medicine and physical therapy are prescribed but the pain persists. So the orthopedist recommends surgery and performs an arthroscopic partial meniscectomy. That’s the technical way of saying that with tiny instruments inserted into the joint through small incisions the doctor visualizes the cartilage tear and shaves away the loose and torn portion, leaving behind only solid intact cartilage. After the surgery more physical therapy is prescribed and over the subsequent months, the patient feels much better. Both he and his doctor agree that the surgery was a success.

This story repeats itself about 700,000 times annually in the U.S. amounting to direct costs of $4 billion. Partial mensicectomies are one of the most common orthopedic procedures. I certainly have never given it a second thought, and have sent patients to orthopedists expecting exactly this treatment. The assumption that the pain is caused by the cartilage tear is so compelling we don’t even notice it.

Previous studies have already shown that arthroscopic knee surgery is ineffective for arthritis. In patients with a cartilage tear and arthritis a study demonstrated that physical therapy and surgery was no better than surgery alone. But for cartilage tears without arthritis the belief remained that the problem was mechanical – the cartilage was torn – and therefore had a mechanical solution – cut away the torn fragment.

Last week’s New England Journal of Medicine (NEJM) published an ingeniously designed trial which tested that assumption. Researchers in Finland enrolled 146 patients with medial meniscus tears and no arthritis. Cartilage tears due to trauma, such as sports injuries, were excluded. Only degenerative tears – those due to chronic use, wear and tear – were enrolled. The researchers knew that surgery itself can have a very powerful placebo effect so they designed a trial that would not reveal to the patients whether or not they had their cartilage repaired.

All the patients underwent arthroscopy – the placing of the scopes into the joint so that the surgeon can visualize the cartilage. If a cartilage tear was confirmed the patients were randomized to one of two groups during the surgery by opening a sealed envelope. One group had the standard surgery, the partial meniscectomy. The other group had sham surgery. The surgeon still asked for all the implements he would normally ask for and in the same order. (Many of the patients had regional anesthesia and couldn’t feel their leg but were awake.) During the part of the sham surgery in which the cartilage was to be shaved the surgeon held a shaver without the blade against the patients knee cap so that his body would experience the vibration and sound of the shaver. The sham surgery patients were kept in the operating room as long as the patients undergoing real surgery. Afterwards the surgical team, the only people who knew the patient’s group allocation, never saw the patient again. All follow up care and evaluation was performed by a different team who were unaware of which groups the patients were in.

The complex blinding scheme worked. Equal proportions of both groups thought they had the real surgery. The patients continued physical therapy and underwent standardized evaluation of their knee symptoms at 2, 6 and 12 months after the surgery. Both groups showed significant improvement, and there was no difference between the groups. About half of both groups reported being satisfied with the procedure, and two thirds of both groups said they would be willing to repeat it.

So it seems that, at least for degenerative tears, the torn cartilage is not the cause of the pain. The torn cartilage is simply a marker of the chronic wear and tear that is causing pain through some other mechanism. The treatment, which appears to be quite effective, is physical therapy and time.

So if this study spared you from an unnecessary surgery, raise a toast to the intrepid Finnish patients who were willing to have surgeons put instruments in their knees and do absolutely nothing for the sake of discovery.

Learn more:

Common Knee Surgery Does Very Little for Some, Study Suggests (New York Times)
Fake Knee Surgery as Good as Real Procedure, Study Finds (Wall Street Journal)
You may not be better off after knee surgery (CNN)
Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear (NEJM article)

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The Last Nail in the Coffin for Multivitamins

pillsHow much money would the US auto industry be making if every car they sold never started? How much could video game console makers charge if their products didn’t play any games? Well, in 2010 the US dietary supplement industry sold $28 billion dollars in vitamins, minerals and other supplements that, as far as we can tell, benefited virtually no one.

The current issue of Annals of Internal Medicine published three studies examining the effects of multivitamins. This is not the first investigation of a mysterious unexplored field. Lots of studies have already shown that in well-nourished people living in the Western Hemisphere, multivitamins are not helpful. Think of this more as sweeping away any traces of doubt.

One study explored the effects of a high-dose vitamin and mineral supplement on heart disease. About 1,700 patients who had a heart attack in the past were randomized to the supplement or a placebo. They were followed for four years to measure their rates of recurrent cardiovascular events. There was no difference in the occurrence of these events between the group receiving the supplement and the group receiving placebo.

Another study examined the effects of a multivitamin on cognitive decline. About 6,000 male physicians aged 65 and older were randomized to a multivitamin or placebo and given a battery of five tests of cognition and memory over 12 years of follow up. The two groups did the same.

The third study was a review of prior studies of vitamin and mineral supplements for the prevention of cancer or cardiovascular disease. The study conclusion was negative. There is no reason to take vitamins or minerals for cancer or cardiovascular disease prevention. And the review highlighted the harms of some vitamins. β-carotene and vitamin A increase lung cancer risk in smokers, and vitamin E increases the risk of prostate cancer.

An editorial in the same journal issue crystalized our current knowledge.

In conclusion, β-carotene, vitamin E, and possibly high doses of vitamin A supplements are harmful. Other antioxidants, folic acid and B vitamins, and multivitamin and mineral supplements are ineffective for preventing mortality or morbidity due to major chronic diseases.

Their conclusion:

The message is simple: Most supplements do not prevent chronic disease or death, their use is not justified, and they should be avoided.

There are specific patient populations who are especially vulnerable to vitamin malabsorption, such as those who have had intestinal surgery and patients on long-term acid suppressing medications. They may be recommended specific vitamin supplements. Women in their child-bearing years should take folic acid. And it’s possible that vitamin D in the elderly prevents falls. But apart from those narrow groups, well-nourished people don’t benefit from supplements. (I don’t take any vitamins or minerals.)

Perhaps the latest studies and the barrage of resulting media coverage will make a difference. Then maybe we could save some of that $28 billion and spend it to buy some skepticism.

Learn more:

Multivitamins Found to Have Little Benefit (Wall Street Journal)
How do Americans waste $28 billion a year? On vitamins, doctors say (Los Angeles Times)
The Case Against Multivitamins Grows Stronger (Shots, NPR’s health news)
Oral High-Dose Multivitamins and Minerals After Myocardial Infarction: A Randomized Trial (Annals of Internal Medicine article. Abstract available without subscription)
Long-Term Multivitamin Supplementation and Cognitive Function in Men: A Randomized Trial (Annals of Internal Medicine article. Abstract available without subscription)
Vitamin and Mineral Supplements in the Primary Prevention of Cardiovascular Disease and Cancer: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force (Annals of Internal Medicine. Available without subscription.)
Enough Is Enough: Stop Wasting Money on Vitamin and Mineral Supplements (Annals of Internal Medicine editorial. Subscription required.)
A Reminder to Dump Your Multivitamin (my post from 2011 reviewing the known effects of various vitamin supplements)

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Meningitis Outbreaks Strike Two Campuses

photomicrograph of Neisseria meningitidis
The microscopic appearance of N. meningitidis: pink-staining spherical bacteria that clump in pairs. Credit: Wikimedia / CDC

Those of us who believe in the unvarying beneficence of Mother Nature have yet to contemplate Neisseria meningitidis. N. meningitidis is a bacterium that can live harmlessly in the throats of healthy people. But about 500 times a year in the US it causes bacterial meningitis, a life-threatening infection in which the membranes lining the brain and spinal cord become inflamed. Bacterial meningitis is treatable with antibiotics but even with treatment patients sometime suffer hearing loss or brain damage. And despite prompt treatment infection is sometimes fatal. When N. meningitidis gets into the blood stream it can cause loss of circulation to the extremities and loss of limbs.

On the first day of medical school I met a classmate who would become a dear friend. She was walking with a cane. During her summer vacation she had lost a couple of toes due to a blood stream infection with N. meningitidis. It would only be later when we studied microbiology that we understood how close to death she came.

N. meningitidis is transmitted between people living in very close quarters. Outbreaks can occur in facilities like prisons, military barracks, and college dormitories. For that reason, most college students are vaccinated against most strains of N. meningitidis prior to attending.

This year two US campuses have had outbreaks of meningitis due to N. meningitidis. Princeton has had seven cases. The first was in March and the most recent in late November. And in the last month four students developed meningitis at University of California, Santa Barbara (UCSB). One of the UCSB students suffered a blood stream infection and had both of his feet amputated.

The two campus outbreaks appear to be unrelated, but both are caused by a strain of N. meningitidis that is not covered by the US vaccine. Health officials have been working to obtain doses of the European vaccine for students in both campuses. Meanwhile hundreds of students who have come into contact with the sickened patients are receiving preventive antibiotics, and crowded gatherings like fraternity parties have been canceled. This is especially sad since it’s my understanding that fraternity parties are the only reason people attend UCSB.

I’m sure the students and parents of both campuses are quite anxious. I hope that both outbreaks are extinguished promptly and that no one else falls ill. And to the student who lost both feet I wish determination and strength and high-tech prosthetics to make the most of what I hope will now be a healthy and long life.

While the public health officials continue their difficult work we are left to retreat to our delusions that nature is benevolent. So we will shop for our organic free-range arugula and our locally-sourced fair-trade hemp sweater vests. And we will do our best to forget that left to her own devices Mother Nature is usually trying to kill us.

Learn more:

Second Meningitis Outbreak Erupts In Southern California (Shots, NPR’s health blog)
Two universities battle meningitis outbreaks (USA Today)
Meningitis outbreak: UC Santa Barbara lacrosse player’s feet amputated (Los Angeles Times)
Why College Campuses Get Hit By Meningitis Outbreaks (Shots, NPR’s health blog)
Bacterial Meningitis (Centers for Disease Control and Prevention)

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A Polio Outbreak in China in 2011

Two weeks ago I wrote about the reemergence of polio in Syria and the Herculean task the World Health Organization faces to eradicate the disease – the vaccination over a million children in the Middle East, some of whom live in a war zone. (See that post for a review of the symptoms of polio and the history of polio eradication in the West.)

This week’s post is about another polio outbreak which was managed very differently. On July 3, 2011 a 16-month-old girl in Xinjiang Province, China became paralyzed. The polio outbreak that followed and the efforts of the public health authorities to track and extinguish the infection are published in an article in this week’s New England Journal of Medicine.

China had eliminated polio by 2000, though it has had small outbreaks of polio imported from other countries since then. The public health response in the summer and fall of 2011 involved a multifaceted attack, including mandatory reporting of all cases of acute paralysis, laboratory testing of patients and their close contacts, and a mass vaccination campaign for vulnerable populations.

Over the subsequent months 21 cases of polio were confirmed and 23 more were suspected but did not yield laboratory confirmation. Over 1,000 health workers were trained to respond to the outbreak and over 43 million doses of vaccine were administered over the following year. A massive media campaign including text messages informed the population of the vaccination program. The study authors estimate that the public health response cost approximately $26 million.

The last confirmed case of polio in the region was in October 2011. The outbreak was stopped within four months of the initial case. Genetic testing of the isolated virus suggested it had been imported from Pakistan, though no contact of the initial patient with a traveler from Pakistan was discovered.

The contrasts between the Syrian outbreak and that in China are stark. The contrast reminds us that a robust public health infrastructure is critical. But in the age of global travel even this well-organized and well-funded public health system was insufficient to keep the country free of polio. The authors of the article and an editorial in the same issue emphasize the point that until polio is eradicated globally even advanced countries will be at risk of outbreaks.

In the meantime, surveillance and vaccination efforts in the US must be recognized as the front line against an ever-present threat. Some parents who are suspicious of vaccines believe that vaccination against diseases like polio is no longer necessary because of the long history of polio eradication in the US. Because of the importance of herd immunity, these ideas were always wrong. As recent outbreaks teach us, these ideas are also very dangerous.

Learn more:

Polio-free countries still face threat, scientists say (Fox News)
Polio Outbreak Can Be Halted in Its Tracks (MedPage Today)
Identification and Control of a Poliomyelitis Outbreak in Xinjiang, China (NEJM article, free without subscription)
No Country Is Safe without Global Eradication of Poliomyelitis (NEJM editorial)
Polio Outbreak in Syria (my post two weeks ago)

Tangential Miscellany

Last week I wrote about new guidelines for cholesterol treatment. Unfortunately a risk calculator that physicians are supposed to use to calculate patient risk of stroke and heart attack seems to be malfunctioning. This New York Times article reports the problem with the calculator. So for now, the fourth group of patients for whom statins are to be prescribed is on hold. I know you join me in hoping that the calculator is fixed soon, perhaps with the help of any spare programmers from the healthcare.gov site.

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New Cholesterol Treatment Recommendations

This week the American College of Cardiology and the American Heart Association released new guidelines for the treatment of high cholesterol. These new guidelines represent a revolutionary change in how patients will be selected for cholesterol-lowering medication and how that medication will be prescribed.

My regular readers (both of them) know well that the family of cholesterol-lowering medicines called statins have long been proven to prevent strokes and heart attacks. It is also well established that an elevated level of LDL cholesterol (“bad cholesterol”) increases the risk of stroke and heart attack. The previous guidelines recommended using statins to lower the LDL to certain specific goals which were lower for patients with higher stroke and heart attack risk. So it involved counting a patient’s risk factors, determining his LDL goal, and then increasing the statin dose until the goal was reached.

The problem with that approach is that there is no evidence that aiming for a specific LDL goal is helpful. We know taking a statin helps, but there is no reason to believe that dialing the dose up or down based on the LDL gives the optimal results.

To understand why this might be the case, let’s think of a couple of other examples. Aspirin is a blood thinner that is well-known to prevent strokes and heart attacks. But the benefit doesn’t depend on measuring anything. Meaning we don’t need to check how thin the blood is to know that the medicine is effective. Everyone gets the same dose (more or less) and that’s that. The same dynamic is present when we prescribe antibiotics for an infection. The dose might be calculated based on the patient’s weight (especially for children) but the dose isn’t adjusted based on the patient’s clinical improvement or worsening. The standard dose is given and is known to be the effective dose.

Statins are slowly moving in that direction. Taking the medicine is known to help, and the goal isn’t reaching a lower cholesterol number; the goal is not having a stroke or a heart attack.

Rather than focusing on which cholesterol levels should receive cholesterol-lowering medications, the new guidelines focus on which patients are most likely to benefit. The guidelines recommend statin treatment for the following four groups of patients.

• Patients who have symptomatic cardiovascular disease. That is, patients who have had a heart attack, a stroke or transient ischemic attack (temporary stroke), angina (chest pain due to narrowing in coronary arteries), bypass surgery or angioplasty, and patients with symptomatic narrowing in any arteries in the body.

• Patients with LDL cholesterol over 190. These patients usually have a genetic cause of their high cholesterol and are at very high risk of stroke and heart attack.

• Patients between the ages of 40 and 75 with diabetes and LDL cholesterol between 70 and 190.

• Patients between the ages of 40 and 75 with LDL cholesterol between 70 and 190 and a risk of stroke and heart attack over the next 10 years of 7.5% or more. A spreadsheet that calculates this risk is available and requires you to know your most recent cholesterol panel and blood pressure.

This last criterion will likely apply to many men in their 50s and women in their 60s, vastly expanding the number of people taking statins.

The new recommendations also state that non-statin cholesterol-lowering medications like niacin and Zetia should not be routinely used since the evidence that they prevent strokes and heart attacks is scant or nonexistent.

The new recommendations have generated some criticism. Some experts claim that they are too complex. Others bemoan the number of people that will now be offered statins. I think the recommendations are actually simpler than what we were doing before. I’m sure we’ll all need some time to get used to them and understand the fine points. My impression is that patients will be able to apply these recommendations much more easily and see for themselves how they compare to the various treatment groups.

As to the criticism that statin use will dramatically increase, if this leads to marked declines in the numbers of strokes and heart attacks then this is not a criticism of the new guidelines but a major improvement over the prior recommendations.

Learn more:

Experts Reshape Treatment Guide for Cholesterol (New York Times)
Shift In Cholesterol Advice Could Double Statin Use (NPR Shots)
New guidelines urge wider use of cholesterol-lowering drugs to reduce heart attacks, strokes (Washington Post)
Panel Unveils Shake-up in Strategy to Cut Heart Risk (Wall Street Journal)
What You Need to Know About New Heart-Care Guidelines (Wall Street Journal, also see the video on the page)
ACC/AHA Prevention Guideline
American Heart Association cardiovascular risk calculator

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Polio Outbreak in Syria

Child in Bangladesh receiving polio vaccine. Credit: Wikimedia Commons / USAID Bangladesh
Child in Bangladesh receiving polio vaccine. Credit: Wikimedia Commons / USAID Bangladesh

If you remember the 1950s you probably remember the terror of polio. Polio, short for poliomyelitis, is a disease caused by a virus which can cause severe inflammation of the spinal cord. Though most infected people have no symptoms, a small fraction of patients are left with permanent paralysis and deformities. The disease is sometimes fatal. In the US, the 1952 polio epidemic killed over 3,000 people and left over 20,000 with some paralysis.

The isolation of the polio virus and the development of effective vaccines still stand among the greatest achievements in public health. After widespread use of the polio vaccines the number of cases in the US dropped precipitously. Polio was eliminated from the US in 1979, from the Western Hemisphere in 1994, and from Europe in 2002.

In the last month polio has resurfaced in a country that is in no position to manage an outbreak – Syria. This is the first polio outbreak in Syria since 1999. Ten cases have been confirmed and twelve others are suspected. At least ten children have become paralyzed. Prior to the war vaccination rates were quite high, but in the last two and a half years the civil war has collapsed the nation’s public health system. The war has also displaced more than nine million people, placing populations in camps with poor sanitation and widespread malnutrition – perfect breeding grounds for communicable diseases. The World Health Organization is scrambling to vaccinate over a million children in Syria and six neighboring countries. Obviously such a massive immunization campaign will be extremely challenging during a war.

Infectious disease experts warn that the infection could spread to Europe as refugees leave the Middle East. Because most cases are asymptomatic there is a concern that the infection could spread very widely through a population before it is detected.

The medical lesson of this tragedy is about herd immunity. Since no vaccine is perfectly effective, and since no community (or “herd”) has every individual vaccinated, there are always a small number of people in any “herd” who are not immune. They stay healthy because the vast number of people that they come into contact with are immune and can’t infect them. So they are protected by the rest of the herd. But as vaccination rates fall, the number of vulnerable individuals increases past a critical threshold at which the likelihood of an infected person spreading the illness to another vulnerable individual is high. At that point the infection can spread throughout the vulnerable members like fire through brush that has just become dry enough to combust.

Children who are denied vaccination because of war deserve our sympathy. But parents in the US who refuse to vaccinate their children because of misguided beliefs deserve our reproach. They do not just jeopardize the health of their children; they weaken herd immunity. Though what is happening in Syria is difficult to imagine in the US, it’s easy to imagine an earthquake or large storm temporarily disrupting sewage and water systems and moving large numbers of people into crowded shelters. In such a scenario unvaccinated people would be like dry kindling waiting for a spark.

Learn more:

W.H.O., Fighting Polio in Syria, Says More Children Need Vaccinations (New York Times)
U.N. Confirms Polio Outbreak in Syria (Wall Street Journal)
A Conquered Foe Returns To War-Torn Syria: Polio (NPR)
Syrian polio outbreak could spread to Europe, experts warn (NBC News)

My post a year ago about malaria’s resurgence in Greece: Revenge of the Parasites

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Tighter Restrictions Coming for Painkillers Like Vicodin

generic Vicoprofen tablets
Generic Vicoprofen tablets. Image credit: Wikimedia/Rotellam1. Creative Commons License

To understand this week’s story we first have to understand how habit-forming medicines are currently prescribed in the U.S. The Drug Enforcement Agency divides potentially addictive substances into different schedules. Schedule II controlled substances are prescription medicines that have a high potential for abuse and severe dependence. They include all the opiate (narcotic) pain medicines, like morphine, oxycodone, and fentanyl. These medications must be prescribed on a paper prescription that has special security markings that prevent copying. The prescription must be taken to the pharmacy by the patient, and cannot be faxed or phoned in. And the prescription can at most prescribe a 90 day supply of the medication without refills.

Schedule III controlled substances are prescription medicines that have less potential for abuse and dependence than the medicines in Schedule II. It includes many medications that include an opiate medicine with a non-opiate in the same tablet. Examples include hydrocodone with acetaminophen (marketed as Vicodin, Lortab, or Norco), tylenol with codeine, and hydrocodone with ibuprofen (Vicoprofen). Prescriptions for these medicines can be called in or faxed by physicians to pharmacies, can be written for more than a 90 day supply at a time, and can include refills.

In the last decade the number of prescriptions for Schedule III pain relievers has skyrocketed, as has the number of people taking hydrocodone for non-medical reasons. Prescription drugs are now a leading cause of addiction.

After years of consideration and debate, the Food and Drug Administration released a statement this week recommending that all pain medications containing hydrocodone be reclassified as Schedule II. The new policy is likely to take effect next year. This would include medications such as Vicodin, Lortab, Norco, and Vicoprofen, as well as their generic equivalents.

Proponents of the plan hope this will stem the tide of prescription medicine misuse. Opponents, like the National Community Pharmacists Association and the American Cancer Society, charge that this will inconvenience legitimate patients seeking pain relief. I suspect both sides are right – both legitimate and illegitimate users of hydrocodone will be inconvenienced.

Though I’m ambivalent about the new policy, I’m reminded of a similar change a few years ago regarding pseudoephedrine (Sudafed), a nasal decongestant. Pseudoephedrine used to be over-the-counter, but because it was being used to manufacture methamphetamine – or crystal meth, a dangerous and illegal stimulant – the new law limited the amount of pseudoephedrine that can be purchased at one time and required that the patient show identification at the pharmacy to purchase it.

My objection to the pseudoephedrine rules is simply that in the several years since the new restrictions, no one has published a study (as far as I know) showing that the street price of crystal meth is higher, that the number of crystal meth addicts is lower, or any other objective measure suggesting that the new restrictions have been effective in decreasing the quantity of crystal meth available on the black market. Nevertheless, regardless of effectiveness, once a tighter regulation is in place, it is never rescinded.

I expect much the same with the new restrictions on hydrocodone – permanent inconvenience without ever measuring whether there is a benefit.

Learn more:

F.D.A. Urging A Tighter Rein On Painkillers (New York Times)
FDA Recommends New Limits on Pain Drugs (Wall Street Journal)
Statement on Proposed Hydrocodone Reclassification from Janet Woodcock, M.D., Director, Center for Drug Evaluation and Research (Food and Drug Administration)

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Musings From the AAPP Conference

AAPP logoLast weekend I attended the fall conference of the American Academy of Private Physicians, a group dedicated to encouraging, organizing, and supporting concierge physicians. Here are the most interesting points I took away from the event.

Ÿ• The most inspirational talk was given by Dr. David Schenck, a medical ethicist at Vanderbilt. He asserted that doctors are effective when they build a healing relationship with their patients. Concierge physicians are uniquely able to take the time to forge such relationships. His lecture was a welcome reminder that despite the technical, economic, and legal upheaval that medicine is undergoing, we are healers first and foremost.

• Though in one form or another concierge medicine has been around for about a decade, there is still no unanimity about what to call our kind of medical practice. Possible names have only multiplied. Names like concierge medicine, direct care, retainer medicine, and private medicine are used interchangeably and I think are needlessly confusing. As I wrote a year ago, once enough doctors do it, it won’t need a name.

• There was widespread agreement that American medicine is about to undergo unprecedented regulatory change. You may think that this is only due to the Affordable Care Act which is just now beginning to be implemented, but the ACA is only part of the regulatory avalanche descending on medicine. Another bureaucratic mess heading our way is ICD-10. ICD is the International Classification of Diseases, a coding system for all diagnoses that are submitted to insurance companies with medical bills. The current version, ICD-9, has about 18,000 diagnosis codes covering all the various ailments that may befall patients. ICD-10 expands it to about 140,000 codes and does so in mind-numbing and self-parodying complexity. The switch from ICD-9 to ICD-10 (which has already been delayed a year) is scheduled for October 2014. It promises to be a boon for health IT consultants who will be guaranteed full employment. But it will likely be an expensive and stressful labyrinth for doctors and hospitals who will have to implement the changes to their billing systems.

Those of us who do not collect a single dollar from any insurance company will be in the fortunate position of avoiding much of the regulatory deluge. We will be able to continue to focus on what’s best for the patient, not what’s covered, and on how to safely confirm the diagnosis, not how to code it.

• Finally, the lecture about marketing our practices was fascinating. It stressed that patients use the web to find physicians, and that physicians should have a frequently updated website, and should engage social media. But there is no marketing tool as powerful as a satisfied patient making a recommendation to someone she knows. We were reminded that many patients might believe that successful physicians have a full practice and are not looking for patient referrals. Our happiest most loyal patients need know that we need them to be our champions in the community. So I ask that you recommend me to your coworkers, colleagues and loved ones. I promise to take great care of them.

We may not be able to control the changes that are about to sweep through healthcare, but physicians can weather the storm by remembering who they work for, and that first and foremost we are healers.

Learn more:

Healing Skills for Medical Practice (Annals of Internal Medicine article, 2008, by subscription only. This should be mandatory reading for primary care physicians.)

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Brain Dysfunction Persists Long After a Serious Illness

Credit: Timothy Comerford / Wikimedia Commons

A sudden life-threatening illness is every family’s nightmare. A loved-one suddenly develops an overwhelming infection or is in a terrible accident. She is rushed to the intensive care unit (ICU) and is put on a ventilator (breathing machine). Many medications are started or she is rushed to surgery for her traumatic injuries. To the family, the first day or two is a blur of life-saving treatments, painfully waiting for the next update. The patient is on strong sedatives and non-communicative. She survives the worst days. The infection improves, or the surgeries fix the worst injuries. The ventilator is removed and the sedation is stopped. It looks like she’s going to make it. Families are usually unprepared for this next stage. In the movies the patient might spring out of bed and return home or a musical montage would convey her complete recovery over the next few days.

In reality the patient spends days in the ICU weak, confused and agitated. She doesn’t sleep. She recognizes loved ones only intermittently and has conversations with people who aren’t there. Other times she’s very lethargic and only answers questions with a word or two. Her family is terrified.

Doctors call this syndrome delirium, and it’s very common in critically ill patients. Delirium manifests in disorientation, agitation, and a level of alertness that can change quickly over time. Though delirium affects all mental process, the primary deficit is in attention. Delirious patients can’t focus on a task or on a question from one moment to the next.

The brain is usually an innocent bystander in delirium. Delirium is almost never caused by a primary brain problem – a stroke or a brain tumor, for example. Delirium is caused by a problem elsewhere that is disorganizing brain function – respiratory failure that is sending the brain too little oxygen or too much carbon dioxide, kidney or liver failure that is sending the brain too many waste products, or an infection that is sending the brain bacterial toxins.

In my training I was taught that once the cause of delirium is found and treated, the delirium might take days or weeks to improve, but that the improvement would be complete. I’ve discussed with many families preparing to take home a loved one that the patient’s periods of confusion would be shorter and the periods of lucidity would be longer, and over the next few weeks her mental status would return to normal. It turns out that’s not true.

A study published in this week’s New England Journal of Medicine (NEJM) sought to measure the long-term mental effects of critical illness. The study enrolled over 800 patients who were admitted to an ICU for respiratory failure, overwhelming infection, or cardiovascular failure (cardiogenic shock) for any medical or surgical reason. The vast majority of them had no cognitive deficits prior to this illness. Their average age was 61. This was an extremely sick group. They spent an average of 3 days on a ventilator and 10 days in the hospital. 74% had delirium, and on average delirium lasted for 4 days. The survivors were followed and underwent a broad battery of neurocognitive tests administered by psychologists 3 months and 12 months after their hospitalization. (For a sense of how desperately ill these patients were, 31% died between their ICU admission and the 3 month follow-up.)

The results were surprisingly poor. Three months after hospitalization 40% of patients had cognition scores that would be typical for a patient with a moderate traumatic brain injury. 26% were even worse and had scores similar to patients with mild Alzheimer’s disease. Twelve months after hospitalization those percentages were only slightly better, 34% and 24% respectively. More shocking was that the rate of prolonged cognitive impairment did not depend on age; young people did as poorly as old. The deficits did correlate, however, with the duration of delirium while they were hospitalized.

This study highlights several gaps in our current care of critically ill patients. Measures are already taken in ICUs to minimize the likelihood and duration of delirium. These measures must be redoubled with the knowledge that delirium may harm patients’ mental function even a year later. Ambulation as early as possible and re-establishing the sleep cycle with daytime alertness and stimulation and nighttime sleep (which requires darkness and quiet) have been two of the more promising methods to protect patients’ mental status.

As important as the ICU care may be the post-discharge follow up. Patients and families should be warned that deficits in thinking and memory may persist for a long time. Just as we prescribe physical therapy for a weak patient going home from the hospital, perhaps we should also be recommending cognitive testing and rehabilitation. And we should keep in mind that patients and their families may require more help than we’ve appreciated for longer than we thought.

Learn more:

Intensive-Care Units Pose Long-Term Brain Risk, Study Finds (WSJ)
Delirium In The ICU May Pose Ongoing Risk Of Thinking Problems (Shots, NPR health news)
Brain problems can linger months after ICU stay (Reuters)
Long-Term Cognitive Impairment after Critical Illness (NEJM article)
Disability after Critical Illness (NEJM editorial)

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A Step Forward for Artificial Limbs

Zac Vawter using the prosthesis prototype. Credit: YouTube
Zac Vawter using the prosthesis prototype. Credit: YouTube

Four years ago Zac Vawter was in a motorcycle collision that severely injured his right leg. He underwent an amputation at the knee, thereby becoming one of the more than one million amputees living in the U.S. Over half of the amputations in the U.S. are due to vascular disease – poor circulation caused by diabetes, smoking, and high cholesterol. Just under half are due to trauma.

Modern leg prostheses that replace both the knee and ankle joint use motors that power each joint and multiple sensors that inform the prosthesis about its orientation, movement, and load. The prosthesis software has several modes or programs that it can execute – walking on a level surface, climbing stairs, even running. To switch modes the user typically uses a remote control on a key fob. So a user might arrive at the bottom of a flight of stairs, push a button to get the prosthesis into “climbing stairs” mode, and then at the top push another button to go back to “walking on level ground” mode.

This week’s issue of the New England Journal of Medicine (NEJM) published a report of a novel prosthesis interface that is much safer and more intuitive. A similar interface has been used to control prosthetic arms, but this has been the first application in a prosthetic leg. Zac Vawter was the subject who worked with the research team and helped them customize and test the prosthesis.

The novel interface uses electrodes that measure electrical activity in the user’s thigh. Prior to using the prosthesis the researchers made multiple recordings from the electrodes as Vawter was told to move his (absent) knee and ankle in various directions. From these recordings software was used to decode his intentions from the electrode signals. The results are a very natural interface. For example when Vawter tries to bend his ankle to point his toes up, his prosthesis senses this and executes his will.

This allows Vawter to go from walking to climbing stairs to descending a ramp by simply thinking about what he wants his prosthesis to do; no manual switching; no remote control. Take a look at the videos in the NEJM report and this YouTube video to appreciate how natural and fluid his gait appears.

Many improvements will be needed before such a prosthetic can be put into production. The current prototype is too heavy, too big, and too noisy. And the researchers say that the software that decodes the electrode signals must be further refined.

This has the potential of making many amputees much more mobile. Of course, as treatment for diabetes, high cholesterol, and vascular disease improves, there will be many fewer amputees in the future. Driverless cars and improved worker safety may decrease the number further.

It will be exciting to watch this technology mature. In the meantime, I wish Mr. Vawter all the best, and I advise anyone who’ll listen not to ride motorcycles.

Learn more:

Man Controls Artificial Leg Using Only His Brain, Researchers Say (WSJ)
First mind-controlled bionic leg a ‘groundbreaking’ advance (NBC News)
Mind-Controlled Bionic Leg Tested (YouTube video)
Robotic Leg Control with EMG Decoding in an Amputee with Nerve Transfers (NEJM Brief Report)

The amputation statistics I cited are from the Amputee Coalition website.

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