Wednesday, February 27, 2013

Image Challenge

In keeping with our GI theme this week, I present to you this image challenge from the New England Journal of Medicine.  This is a loop of bowel removed from a child from Kenya.  In case you aren't familiar with the appearance of bowel, I can tell you this is not normal.  What is the diagnosis?
Make your best guess in the comment section and I will post the answer tomorrow.

1.  Ascariasis
2.  Kala-azar
3.  Meckel's diverticulum
4.  Strongyloidiasis
5.  Trichobezoar

Click on the Image for a better view and go for it!

Sunday, February 24, 2013

Fecal Microbiota Transplants

Yes, you read it right.  I said "Fecal Transplants".  It may sound disgusting but there is increasing evidence that placing a healthy patient's feces inside the GI tract of a patient with Clostridium difficile gut infection may be the wave of the future.  And it shows just how important our normal gut microbe flora is for good health.  Here is how it works:

Our GI tracts are colonized by hundreds of microorganisms at birth as we pass through the mother's birth canal.  These bacteria live in  balanced homeostasis, helping digest food, helping absorb Vitamin K and Vitamin B complex and helping our immune response.  When this balance is upset with antibiotics, Clostridium difficile bacteria overgrowth can occur.  Clostridium difficle infection is serious and it is the most common cause of hospital acquired diarrhea and often leads to severe illness and death. As patients are treated with yet more antibiotics to eradicate the infection a month later recurrent C. diff  can commonly return.

Fecal microbiota transplantation involves taking stool from a healthy donor (a relative is best) and instilling that stool into the GI tract of the infected patient.   The donor is screened for HIV,  hepatitis, syphilis, parasites and C difficile.  The stool is made into a slurry with saline in a household blender and then instilled into the patient.  This can be done with a nasogastric tube directly into the stomach or placing it in the colon with a colonoscope or enema. A recent multicenter long-term follow-up study showed that diarrhea resolved within 90 days after fecal transplantation in 91% of patients.  Some patients also reported to have improvement of preexisting allergies and peripheral neuropathy and other autoimmune diseases.   And a study published in the New England Journal of Medicine in January, 2013 showed infusion of donor feces was significantly more effective for the treatment of recurrent C difficile infection than the usual treatment with Vancomycin.

The Human Microbiome Project is focusing on understanding the role of human genetic and metabolic bacteria that may help other diseases such as inflammatory bowel disease, irritable bowel syndrome, multiple sclerosis, rheumatoid arthritis and sjogrens syndrome.  These early trials point to the benefits of millions of microbes in our bodies and one can't help but wonder about our factory farmed animal food supply that is so injected with antibiotics and how that may contribute to disease.

Fecal transplants make a lot of sense as we appreciate more and more how important it is to have healthy gut microbes.  To keep your gut healthy please:

1.    Avoid antibiotics unless necessary for a known serious bacterial infection
2.    Buy only organic, local farmed meat and poultry that has not been fattened with antibiotics
3.    Eat more fiber, fruits, vegetables and legumes
4.    Drink water between meals

Wednesday, February 13, 2013

Price of Health Care a Mystery for Patients

You have a $5000 annual deductible and need a test or treatment.   It should be easy to find out upfront what it will cost, right?  Good luck with that one!

I've written before about the problems with health care price transparency and hidden costs but there hasn't seemed to be much improvement over the years.  A new study published in the Journal of the American Medical Association (JAMA) found that only 16% of hospitals surveyed were able to provide an estimate for the total cost of a hip replacement procedure.

The researchers surveyed 122 hospitals covering all 50 States and asked each hospital to estimate the cost of a hip replacement for a 62 year old, uninsured individual who would pay "out-of-pocket".   They found that:
  • Only nine of the 20 orthopedic hospitals and 10% of the other hospitals could provide a full cost estimate for hospital and physician fees after a minimum of five phone calls;
  • 12 of the orthopedic hospitals could provide a complete cost estimate after the researchers contacted the hospital and affiliated physicians separately; and
  • 54 of the remaining hospitals could provide a complete cost estimate after the hospitals and affiliated physicians were contacted separately.
  • Many of the people they asked at hospitals seemed perplexed with the question and many times researchers were told they needed to make an office visit just to get an estimate.
Now are you ready for this?  The cost estimates varied from $11,000 to more than $125,000.

It is unlikely that they were comparing apples to apples.  Some estimates failed to cover physician fees or all costs but still, the question was quite simple and direct.  They also found no correlation between high cost and top-ranked hospitals and there is no data that shows certain high cost hip implants were better than cheaper options.

There is no way consumers can be "market driven, cost conscious" if they can't get accurate pricing information. And there is really no justification for the price variance.  It can't be explained by quality outcomes or any other measure.

If you live in the USA, you cannot be an informed consumer of health care. 

Sunday, February 10, 2013

Technology and Health Care

One of my tennis friends asked me about new innovative smart phone technology and why it hasn't been embraced in health care.  She had just watched a video about Dr. Eric Topol, Chief Academic Officer at Scripps Health in San Diego, and his demonstrations of how a smart phone could monitor blood sugar, take EKGs and cardiac ultrasounds and really deliver health care to the patient at home. 

My friend's question; "If this technology is here, why isn't it being used?"

According to Dr. Topol, new apps for the smart phones could eliminate 80% of echocardiograms that are done in facilities at costs between $300-$1500 each.  Having patients come into the office when they experience symptoms or for diabetics to get their blood sugar regulated could be eliminated.  New technology could be data driven and personalized and save millions of wasted dollars in health care.  So why is medicine so far behind the innovation curve?

The answer:  No-one pays for it. 

Why aren't all physicians using email to communicate with patients and save them an office visit?  The  politically correct answer is "remote medicine is not as good as seeing the patient in person and making sure the diagnosis is correct".  The real answer is:   No-one pays for it.

United States health care has complicated payment systems for work done.  The payor for health care services is either Medicare/Medicaid (CMS)  or hundreds of different (for-profit) insurance companies.  CMS sets the payment rules that everyone follows.  Medicare and all insurers will only pay for face to face visits.  Reimbursement is for doing more and the more you do the more you get.

The doctor that tries to save a patient time and travel by covering a number of problems in one office visit will not be rewarded and, in fact, will be reimbursed less.  If you do a skin biopsy on the same day you do a visit for arthritis flare, CMS and insurance companies will not pay for both things.   Do them on separate face to face visit days and...voila...a better reimbursement for your time and skill.

Email, remote monitoring, remote echocardiograms, discussing tests via a smart phone are freebies.  No patient visit means no reimbursement.  The cost of putting in high technology is borne by the physician too.

Most physicians and hospitals and surgery centers and labs and pharmacies are happy with this status quo.  There is great fear of change and so we continue to spend more on health care than any Nation in the world.  We do wasteful mass screenings and 1/3 of all prescriptions are a waste.  People who need care are not getting it and others are getting too much that they don't need.

ObamaCare is trying to make some gradual changes by supporting pilot programs to change the way healthcare is delivered.  But it is slow going and innovative answers are out there.  If we could just figure out how to pay for services, while using new cost-saving technology we would all be following Dr. Topol's future dream.

Thursday, February 7, 2013

New Info on Tennis Elbow

New information has come out on what works and what doesn't work for lateral epicondylitis...aka: tennis elbow.  A new study published in JAMA will change how we have treated this condition for decades.

Being a tennis player myself, I have suffered from this condition.  The outside elbow, where the lower arm tendon inserts on the epicondyle bone gets inflamed and swinging a racket or even lifting a carton of milk out of the refrigerator can cause excruciating pain.  This is a very common condition and can be caused by any repetitive motion of that muscle.  One of my patients got it from clipping roses.  Traditionally the treatment is anti-inflammatory medication (ibuprofen, aleeve), ice and rest.  For serious cases, physiotherapy and injection with a corticosteroid has always proved effective in my practice.

The researchers found, however, that patients treated with a single corticosteroid injection had a 14% greater chance of poor outcome and a 77% increased risk for re-injury at 1 year relative to placebo. Eight weeks of physical therapy appeared to have no long-term benefit with the exception of decreased analgesic use.

The researchers compared corticosteroid injection with placebo injection and found no difference at one year.  The corticosteroid injection did reduce pain at four weeks compared to placebo injection.  At 26 weeks that corticosteroid injected patients did worse than the placebo injection.  Physiotherapy patients had better pain relief at 4 weeks but no difference at one year.

How can we explain these results?  The decreased pain relief at 4 weeks may have allowed the patient to resume activity or engage in excessive activity before the healing was complete.  Pain is the body's way of telling us to do something different. 

The take home message here is that we need to be willing to change our treatment modalities as new evidence is presented.  Lateral epicondylitis is a condition that will benefit short term from physical therapy and corticosteroid injections should not be done.  As difficult as it is for a tennis player, resting the tendon and allowing the body to heal is the best medicine.

Tuesday, February 5, 2013

Baby Boomers Health Lags

The baby boomers are strictly identified as being born between 1946-1964.  The boom lasted 19 years and delivered 76 million total births.  "Leading Edge" boomers were between 1946 and 1955.  They were the generation that were the wealthiest, most active, and most physically fit generation that had ever lived.  They were special and expected to have better lives than their parents.

Well, those leading edge boomers are now middle age and getting AARP bulletins.  And a new study published in The Journal of the American Medical Association  reveals their overall health status was lower than prior generations, with only 13.2% reporting 'excellent' health compared with 32% of individuals in the previous generation (P < .001). To really paint the picture, researchers reported more than twice as many baby boomers used walking assist devices (6.9% vs 3.3%), more were limited in their work by disability (13.8% vs 10.1%), and 13.5% vs 8.8% were coping with some type of functional limitation.

But wait...that's not all.

In addition, more baby boomers are obese compared with the previous generation (38.7% vs 29.4%), and they reported exercising significantly less often (35.0% vs 49.9% exercised >12 times per month). In fact, more than half the baby boomer respondents said they engaged in no regular physical activity (52.2% vs 17.4%). 

How can this be? The baby boomers have the benefit of great scientific research, all the health information in the world available on the internet and they are fat and sedentary?

These same baby boomers make up 26.1% of the U.S. population. That is a lot of unhealthy people.

So if we piece this study together it means that these baby boomers may live a few years longer than prior generations but they are more likely to suffer chronic illness and be unable to care for themselves.

As a baby boomer myself,  I find this study to be alarming and depressing at the same time.  It's not too late for boomers to save themselves and save their children from the burden of caring for them.  They can start with learning the toxic effects of sugar and pre-packaged foods.  Instead of going to Wallmart and buying more stuff we don't need, how about starting a rooftop garden or a walking group with friends.  Buy a pedometer and a blood pressure monitor and take charge of your health.

I know this sounds preachy but this is just plain "messed-up" (as my 17year old would say). Baby Boomers, save yourselves!  I don't want to watch everyone in an electric cart as I get older and I know there won't be enough doctors to take care of all of the chronic disease.

When to Use Urgent Care

We all know that Emergency Departments are over-crowded with long waits and exorbitant fees.  Free standing Urgent Care is a great solu...