What We Don’t Know About Diabetes – Part 2

In February I wrote about the results of the ACCORD trial, a study designed to test whether strict glucose control in patients with diabetes helps prevent strokes and heart attacks and prolongs life.  The startling results were that the patients with diabetes who were randomized to have their glucose lowered to normal levels died sooner than those with more lax sugar control.

This week the New England Journal of Medicine published the results of another study, the ADVANCE trial, which was designed to answer the same question.  Over eleven thousand patients with type 2 diabetes were randomized to two groups.  One group was managed intensively with a goal of normal blood glucose.  The second group had less strict sugar control.  The groups were followed to measure the frequency of strokes, heart attacks, worsening of kidney disease, diabetic eye disease and death.

Again, in this trial, strict sugar control did not save any lives (though at least, it didn’t cause extra deaths like in ACCORD).  Strict sugar control also didn’t prevent strokes, heart attacks or eye disease.  The one benefit that was detected was that patients with strict control had less kidney disease than patients with lax sugar control.

The common theme seems to be that normal sugars are not the goal of diabetic treatment, or at least not the only goal.  Heart attack and stroke prevention in patients with diabetes involves many other proven therapies like smoking cessation, cholesterol lowering with statins, blood pressure medications and aspirin.

Learn More:

My post in February about the ACCORD trial:  What We Don’t Know About Diabetes

The New England Journal article publishing the results from the ADVANCE trial:  Intensive Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes

The New England Journal article publishing the results from the ACCORD trial:  Effects of Intensive Glucose Lowering in Type 2 Diabetes

Tangential Miscellany:

I hope us dads all get to spend some time with our kids this weekend, and all of us who are fortunate enough to still have our fathers in our lives have a chance to express our love and gratitude for everything they’ve done for us.  Happy Father’s Day!

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Flip-Flop Hubbub

As summer approaches, researchers at Auburn University have performed a study demonstrating the dangers of that ubiquitous summer accessory, the flip-flop.  They recruited volunteers and recorded their gait in both sneakers and flip-flops.  In flip-flops the subjects took shorter steps and didn’t raise their toes as far as they did in sneakers.

This makes sense, if you think about it.  When we wear flip-flops we curl our toes down to keep the sandals from flying off our feet.  This keeps us from taking a long step and also has our heel hit the ground at the wrong angle for optimal walking.

The investigators warn that this abnormal gait could contribute to foot and knee pain in people who walk long distances in flip-flops.  I’m sure this news ruins your day, if not your summer, but don’t despair.  The authors reassure us that wearing them for short distances like around the pool should be fine.

So when you see me at the beach in my wingtips, now you’ll know why.

Learn More:

ABC News article: Flip-Flops Can Cause Long-Term Health Problems

New York Times Health blog: Summer Flip-Flops May Lead to Foot Pain

Tangential Miscellany:

This week, I’d like to leave you with the eloquent rant of my patient Stephen J. who emailed me to vent about the problems with medical insurance.  I couldn’t have said it better.

Reason 4,327,602 to be critical of health insurance: “The Ticket Punch.”

Here is how it works.  Medical insurance companies pay by the visit.  Doctors need volume.  When a patient visits a doctor with a new complaint the doctor may need to “waste time” errr “spend time” diagnosing the problem.  The flat payment doesn’t cover the time.  So when the doctor sends the patient for an MRI, reviews the MRI and concludes that the patient should see a surgeon, he makes the patient come in before telling him that.  The patient would be better off to hear that in a phone call.  The other patients in the crowded waiting room would be better off too but the doctor can’t bill for the call and needs to “punch his ticket” in order to be paid.

Doctor’s used to validate parking; now patients punch billing chits for doctors.

I like the idea that a doctor can value a patient’s time and be paid to do so.  And I like parking validations.

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Patients Want Education, Not Just Medication

I’ve written before on the increasing danger of bacteria that are resistant to multiple antibiotics.  This resistance is a side effect of the use, and frequent misuse, of the many antibiotics physicians have at our disposal.  I’ve also written about the pressure that physicians sometimes face from patients to prescribe unnecessary antibiotics.

Last week Slate published an article by Dr. Zachary Meisel, an emergency department physician who recounts facing a very common dilemma.  He took care of an infant with a cold whose mom clearly expected a prescription for antibiotics.  Knowing that antibiotics won’t help the baby, but not wanting to dissatisfy the mom, what was he to do?  (Why an infant with a cold would be in an emergency room rather than in her pediatrician’s office is a vast subject for a different post.)

Dr. Meisel cites a recent study that examined patient expectations for antibiotics and their satisfaction with the care they received.  The study concluded

“Patient satisfaction was not related to receipt of antibiotics but was related to the belief they had a better understanding of their illness.”

So for most patients, education about the disease is more valuable than a prescription.  This is an important lesson for us doctors to learn.  A prescription may take only 30 seconds to write, but ten minutes of teaching is better for the patient and for society.  This is another example of an instance in medicine in which efficiency and quality diverge, and doing the right thing takes some time.

So what did Dr. Meisel do?  To find out, I urge you to read the Slate article.

(Thanks to Luetrell T. for pointing me to the Slate article.)

Learn more:

Slate article:  The Pink-Bubble-Gum- Flavored Dilemma — Why doctors give out antibiotics you don’t need

My post about the pressure to prescribe unnecessary antibiotics: Acute Bronchitis

My post about resistant bacterial infections: Serious MRSA Infections More Common

Annals of Emergency Medicine Study: Antibiotic Use for Emergency Department Patients With Upper Respiratory Infections: Prescribing Practices, Patient Expectations, and Patient Satisfaction

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Smoking and Quitting Are Social Behaviors

“But he can’t be a man ’cause he doesn’t smoke
The same cigarettes as me.”
— Rolling Stones, (I Can’t Get No) Satisfaction

An article in this week’s New England Journal of Medicine illuminates the social dynamics of smoking and quitting, and generated a lot of attention in the media.  The study followed twelve thousand people, many of whom were initially smokers, from 1971 until 2003.  The large group was all connected in one large social network, meaning all of them were connected to each other through friendship and marriage.

The study followed this large group for 32 years and studied the social patterns of those who quit smoking.  The results showed that smokers very frequently quit in social groups, not alone.  So when one smoker quit, it was very likely that much of the social network directly connected to her quit as well.  This suggests that quitting smoking is much more of a group behavior than an individual decision.

Interestingly, as time went on, those who remained smokers became increasingly marginalized in the social network, as those with the most social connections became the least likely to smoke.  So it appears that the social status associated with smoking a generation ago has reversed.  It’s finally cool to quit.

Learn more:

New York Times article:  Study Finds Big Social Factor in Quitting Smoking

New England Journal of Medicine Article:  The Collective Dynamics of Smoking in a Large Social Network

New England Journal of Medicine Editorial:  Stranded in the Periphery — The Increasing Marginalization of Smokers

A fascinating animation of the data in the study

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Osteoporosis Screening: Not Just for Women Anymore

Osteoporosis, which means very low bone density, is a major risk factor for fractures.  Fractures can be catastrophic for older people, and effective medicines exist to treat osteoporosis and prevent fractures, so detecting osteoporosis before a fracture happens is very important in older patients.  Since osteoporosis is very common in postmenopausal women, screening them for osteoporosis is a well-established part of preventive care.

Though men are less likely then women to have osteoporosis, a fracture in an older man is just as potentially catastrophic.  Until now, no clear guidelines have been available to guide physicians about whether or when to screen men for osteoporosis.  Frequently, therefore, osteoporosis has been diagnosed in men after the first fracture.

This week, the Annals of Internal Medicine published a review of the medical literature about screening men for osteoporosis, and on the basis of this review, the American College of Physicians issued a clinical practice guideline for screening men for osteoporosis.  Their recommendations are:

  • Clinicians should periodically perform individualized assessment of risk factors for osteoporosis in older men.
    Risk factors for osteoporosis are

    • age (>70 years)
    • low body weight (body mass index <20 to 25)
    • weight loss
    • physical inactivity
    • corticosteroid use
    • androgen deprivation therapy
    • previous fragility fracture
  • Clinicians should obtain dual-energy x-ray absorptiometry (DEXA bone density scans) for men who are at increased risk for osteoporosis and are candidates for drug therapy.

Though much is still not clarified, like the number of risk factors that should prompt screening or the frequency with which screening should occur, this is a valuable start.  So if you’re an older skinny sedentary guy (or if you love one) ask your doctor about getting a test for osteoporosis.

Learn more:

The American College of Physicians clinical practice guideline:  Screening for Osteoporosis in Men

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When Less Care is More

Doctors are trained to try to figure out what’s wrong and fix it.  We’re trained to make a plan and execute it, to do something.  But that impulse to order the next test, prescribe the next therapy or do the next procedure can harm our patients if it’s done without consideration of the patient’s goals.  That’s particularly true with older frail patients whose quality of life is decreasing.  In our reflexive rush from symptom to test result to treatment, we may never stop to think that the treatment may cause as much harm as good, and that the benefit we hope for is unrealistic.

This week the NY Times had an important article about a geriatric program that educates patients and their families and puts their goals first.  The program is called “slow medicine” because at each step there is time for questions, answers and deliberation.  With this perspective a futile hospitalization may be avoided, a surgery that is unlikely to impact the patient’s overall course may be refused, a loved one’s wishes about her last days may be honored.

If you are caring for a loved one who is in the last chapters of his life, I urge you to read the article.

Doctors need to relearn that life-saving is only temporary and that comfort is sometimes the best treatment we can offer.  Families and patients need to learn to ask difficult questions and to find doctors who will answer them.

(Thanks to Dr. Mark Urman and to Andrea G. for bringing the article to my attention.)

Learn More:

New York Times article:  For the Elderly, Being Heard about Life’s End

Tangential Miscellany:

Happy Mother’s Day to all the moms out there!  Thank you for the years of sacrifice, work and worry.

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U.S. Measles Cases at Highest Numbers Since 2001

I almost never write about children’s health.  I’m not a pediatrician, and most of what I know about kids’ health I learned as a dad, not in training.  This topic, however, is important enough to concern all of us.

Measles is a very contagious viral illness that causes high fever, a rash, cough and a runny nose.  Complications can include pneumonia, brain inflammation and death.  In 1958 there were 763,094 cases of measles reported in the US.  The measles vaccine was introduced in 1963, and widespread vaccination has nearly eliminated measles in the US, with fewer than 150 cases annually since 1997.  In 2000 endemic US transmission (contagion from patient to patient in epidemics) was declared eliminated.

This year 64 cases of measles have been reported in the US so far, making it the largest number of cases since 2001.  Twelve cases were in California.  No deaths have been reported.

All but one of the patients were unvaccinated or had unknown vaccination status.  The one vaccinated patient with measles reminds us that the vaccine is very effective, but not perfect.  Being vaccinated is not a guarantee of immunity, and part of the protection that each child has is the crowd of vaccinated children around her.  Some of the 64 children with measles this year were too young to have been vaccinated, but 14 of them had claimed exemptions from the vaccination because of religious or personal beliefs.

On almost all issues of controversy I side with patient autonomy and individual liberty.  I certainly would not advocate overriding the parents’ right to refuse vaccinations on behalf of their children.  But I would assert that these parents are reckless, and I don’t want their children in the same school cafeteria, playground, or pediatrician waiting room as my kids.

Learn more:

New York Times article: Measles in U.S. at Highest Level Since 2001

Centers for Disease Control and Prevention feature:  Measles Update: Outbreaks Continue in US

Morbidity and Mortality Weekly Report early release: Measles — United States, January 1 – April 25, 2008

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Home Defibrillators Less Helpful than Hoped

Automatic external defibrillators (AEDs) are machines that are designed to be used by non-medical personnel in the event of a witnessed sudden collapse.  The AED is connected to the chest of the patient and automatically detects the patient’s heart rhythm.  If the AED detects a rhythm that requires an electric shock, the AED delivers the shock and monitors the rhythm until paramedics arrive.  The time between collapse and delivery of the first shock is critical to survival.  So it was hoped that home AEDs would help patients who are at very high risk of heart attacks.

A large study which will be published in the New England Journal of Medicine tomorrow studied 7,000 patients who had a recent heart attack but didn’t need an implantable defibrillator.  They were randomized to two groups.  One group received home AEDs, and the families were instructed that in the event of a witnessed collapse, the family member would use the AED, call paramedics and then do CPR.  The second group did not receive AEDs, and the plan in the event of a witnessed collapse was to call paramedics and do CPR.  The groups were followed for about a year and a half.

Disappointingly the groups did similarly, with about 2% of the patients dying in each group annually.  Part of the reason that the group with AEDs didn’t do better is that they were used so infrequently.  In a group of 7,000 patients, 123 cardiac arrests happened at home, and only 63 were witnessed.  The AED was used on only 29 patients, and only 14 patients had rhythms for which shocks were delivered.

This bad news may actually be a victory for the medical care of heart disease.  From other studies a decade ago, the authors of this study expected an annual death rate closer to 4% in this high risk group, but the medical treatment of heart disease has improved substantially in that time, with more aggressive goals for cholesterol lowering and more universal use of aspirin and proven blood pressure medications.  So patients are surviving longer after heart attacks and fewer are in the desperate situation in which an AED can help.

So if you’ve had a heart attack, don’t invest in that external defibrillator.  It’s a much better bet to take all the right medications and never need an AED.

Learn More:

The study in the New England Journal of Medicine: Home Use of Automated External Defibrillators for Sudden Cardiac Arrest

An editorial in the same issue: Can Home AEDs Improve Survival?

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Insurance for Routine Care: An Idea Whose Time Has Passed

Patients paying doctors directly for their care is best for patients, best for doctors, and best for the country.  Most of my patients know that this simple idea has been my obsession for the last few years.  Initially, I thought this idea was just a good way to reorganize my practice.  But now, with Medicare within a decade of insolvency, with decreasing numbers of medical students choosing primary care as a career, with increasing numbers of patients finding good primary care either unavailable or unaffordable, it is an idea that deserves broader attention.

Coincidentally two op-ed articles this week made the point that insurance for routine care is a big part of what’s wrong with American healthcare.

Tuesday, Jonathan Kellerman, a psychologist and a renowned author of mystery novels, wrote an op-ed in the Wall Street Journal comparing health insurance companies to the Mafia.

Today, the LA Times published an op-ed (by me!) asserting that customer service is better in most doughnut shops than in most doctors’ offices, and insurance interference is partly to blame.  In it, I try to convince doctors to give up the insurance business model for simple retail medicine — the doughnut shop model.

I urge you to read both articles and pass them around to friends and colleagues, especially to physicians.  Thank you for spreading my obsession.

Learn more:

“Dollars to Doughnuts Diagnosis” by Albert Fuchs

“The Health Insurance Mafia” by Jonathan Kellerman

Tangential Miscellany:

Happy Passover to all my Jewish readers!

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It’s Never Too Late to Treat High Blood Pressure

New Feature
Ask the Doctor

I’ve read a lot in the news in the last two weeks scary stuff about Singulair.  Should I stop taking it?
— Jeff K.

About two weeks ago the FDA released a communication that it was investigating the incidence of suicidal thinking and mood changes in patients taking Singulair, a medication used to treat asthma and nasal allergies.  No connection between Singulair and these symptoms has been established.  So there’s no reason to stop your medication, but obviously let your doctor know about any changes in mood or any thoughts of hurting yourself.

Please email me health-related questions that you think would be of general interest.  Unless you ask me not to, I’ll identify you only by your first name and last initial.

* * *

It’s Never Too Late to Treat High Blood Pressure

Preventive care in older patients is always a tricky balance.  As patients get older, the conventional thinking goes, their life expectancy decreases, so there is less opportunity for preventive care to make a difference over many years.  Also, older people tend to be more sensitive to medication side effects, so the likelihood of harm of any therapy is greater.  For example, if lowering blood pressure only prevents strokes and heart attacks after many years, are older patients going to live long enough to benefit?

A study in the New England Journal of Medicine that will be published in the May 1 issue definitively answers that question.  The study randomly assigned 3845 patients who were 80 or older and had high blood pressure to receive either blood pressure lowering medication or placebo.  They were followed for an average of about two years.

Surprisingly, the patients on the blood pressure medications did quite a bit better without any increase in adverse effects from the medications.  The patients on blood pressure medications had fewer strokes, heart attacks and death from any cause than those on placebo.  For every about 60 patients taking medication instead of placebo for one year, one cardiovascular event was prevented.  That’s much more benefit than was expected in this age range.

So don’t give up on your blood pressure because you think you’re too old to have to worry about it.

Learn more:

The FDA early communication about Singulair

The New England Journal of Medicine study “Treatment of Hypertension in Patients 80 Years of Age or Older”

An LA Times article covering the findings of the study

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