When the online physician discussion site, Sermo, and the American Medical Association joined forces in 2007, it was heralded as a promising partnership for both entities.

In fact, as Sermo’s CEO Daniel Palestrant said back then, “As a company, we had to take a very rational perspective on that by saying we’re a small software company, not an advocacy organization. Who is the best entity to turn voice into action? Without a doubt that’s the AMA.”

And the AMA was no less enthusiastic: “Engaging with Sermo’s virtual community adds to the resources the AMA can call upon to rapidly assess and respond to the issues and concerns of physicians across the United States.”

Well, fast forward to July 2009, and now they have parted ways. And like many divorces, it’s messy.

Scott Shreeve has published a missive that Dr. Palestrant posted on Sermo on July 1st, rebuking the AMA:

As physicians, our first step in the healthcare debate needs to be clearing the air about who speaks for us on what topics. Today, I am joining the increasing waves of physicians who believe that the AMA no longer speaks for us. As the founder and CEO of Sermo, this is a considerable change of heart, given the high hopes that I had when we first partnered with the AMA over two years ago. The sad fact is that the AMA membership has now shrunk to the point where the organization should no longer claim that it represents physicians in this country.

I asked the AMA to comment on the situation, and last night, they answered with this reply:

The AMA has decided not to continue its business relationship with Sermo.

The AMA is always looking for effective ways to communicate with physicians. After an evaluation of the initial relationship with Sermo, we have decided that the value was not there to justify the investment of AMA members’ dues dollars. We continue to explore ways to communicate more effectively with all physicians.

Furthermore, they also sent me their response to Dr. Palestrant’s remarks, writing, “As for Dr. Palestrant’s sudden ‘change of heart’ regarding the AMA, one can only speculate. He ardently courted the AMA when launching his business two years ago, and now he expresses scorn immediately following the end of that business relationship.”

I am a member of Sermo, and support what they are trying to do. They’ve made great strides since their inception several years ago.

I also support the AMA’s initiatives, and indeed, they are regular contributors on this blog. It’s a shame that the situation has degenerated into such an ugly situation.

I also understand the sentiment within the physician community that the AMA may not represent the majority of doctor’s interests, and wrote about it a few weeks ago. But, they’re the best advocacy organization we have, like them or not, which is important in the current health reform environment. As such, perhaps it’s not the best time for physicians to bicker among themselves.

Politicians will find it easier to ignore multiple, fragmented physician advocacy groups rather than a single, unified physician voice.

So, while I can sympathize with Dr. Palestrant’s concerns, which undoubtedly echo those of many other doctors, I’m not sure bashing the most influential physician advocacy organization in the country, in terms of Congressional lobbying power and money, is the most productive strategy right now.

Posted at KevinMD.com. Stay updated and subscribe or follow me @KevinMD on Twitter.

Classic.

(via Dr. Val)

Posted at KevinMD.com. Stay updated and subscribe or follow me @KevinMD on Twitter.

Happy Fourth of July Weekend, Everyone! In light of yesterday’s post, I felt I should offer some sort of assistance in dealing with the inevitable onslaught of food this holiday weekend. This information is adapted from a great piece by John Crowley, my co-host over at DiabeticConnect, and applies to just about any big-food holiday (aren’t [...]

Twitter is a microblogging service where people answer the question "What are you doing?" via 140-character messages from their cellphone, laptop or desktop. You can select the messages (called "tweets") that you find interesting, useful, amusing, or disagreeable. Here is the 71st edition of My Twitter Favorites.

1. 
   bgaustin Forget the past. No one becomes successful in the past. 2:16 PM Jun 22nd from Tweetie
   
   
2. 
   DrGSHenderson Admiring the geometric sunburn pattern on my feet and using the Pythagorean theorum 2 calculate my insole http://twitpic.com/845hc12:51 PM Jun 22nd from Tweetie
   
   
3. 
   scanman If the moustache goes, you go! ☜ Direct quote from my wife, @dermdoc9:44 PM Jun 21st from Power Twitter
   
   
4. 
   loic this coffee is so strong I am jumping all around the place but still happy I have found it 1:16 AM Jun 21st from Seesmic_
   
   
5. 
   Pogue Love the new Shredded Wheat TV ad, pointing out no recipe changes in 100 years: "We put the NO in innovation!" 11:44 AM Jun 20th from TweetDeck
   
   
6. 
   NaseemMiller Working on a story about aging pop. To control cost, one doc says a 99 y.o. shouldn't have cataract surgery. What if the patient wants it? 10:39 AM Jun 20th from web
   
   
7. 
   pierre Today learned benefit of wearing a tie: dribbled coffee all over myself, tie caught it all, and dried itself in minutes. 5:56 PM Jun 19th from Twitterrific
   
   
8. jeffjarvis Forbes: "Skip this welcome screen...." Why aren't they just honest and call it an ad? They need ads. I get that. I need no welcome, though. 5:35 PM Jun 19th from Tweetie
   
   
9. 
   bencasnocha"In retrospect, all revolutions seem inevitable. Beforehand, all revolutions seem impossible.” - Michael McFaul, democracy expert on the NSC 3:03 PM Jun 19th from web
   
   
10. 
    Pogue TONIGHT'S MEDITATION: I used to work in a blanket factory, but it folded. 1:27 PM Jun 19th from TweetDeck
    
    
11. 
    pkedrosky I am convinced the prolific @pogue 's #1 productivity tip is always overlooked: "I work from home. That's 2-3 hours more time each day ..." 12:40 AM Jun 19th from twhirl
    
    
12. 
    AllergyNotes I believe we had the first ever Journal Club on Twitter on Dec 11, 2008 http://bit.ly/ZkDn0 - please reply @JRBtrip to expand the idea 6:07 PM Jun 18th from TweetDeck
    

The inclusion of a Twitter update (tweet) in Selection of My Twitter Favorites does not represent endorsement or agreement of any kind.

If you are included in this post but you would like to have your tweet removed for any reason, please email me and will comply with your request the same day.

Micro-blogging on Twitter is easy, fun and can be useful and educational if you follow/subscribe to interesting people. You can read more here: A Doctor's Opinion: Why I Started Microblogging on Twitter and visit my account at Twitter/AllergyNotes.

1. Stabilize acid-base status
2. End-of-life discussion
3. Nuclear medicine stress test in woman with recent NSTEMI
4. Cellulitis which followed a traumatic amputation
5. Hyponatremia secondary to psychogenic polydipsia and (perhaps) thiazides, presented as altered mental status
6. Achalasia – needs myotomy
7. Lung cancer with bony metatases – needs biopsy documentation
8. Patient s/p below knee amputation for gangrene – awaiting rehab placement
9. Severe tonsillitis – probably bacteremic – responding to clindamycin

The first patient was very complex. He was in the ICU after an in-hospital arrest. He had multiple medical problems, and develop ATN 2 days later.

The second patient died the next morning. My resident and I spent 30 minutes preparing the family for the inevitable. Our time investment brought reality to a family, and helped the nursing staff greatly (their report to us).

The third patient was admitted for a TIA and happened to have elevated troponins. Her stress test was negative.

The fourth patient did very well – he had a minor amputation of the tip of his toe. His response to IV antibiotics was dramatic.

The fifth patient had a rapidly improved sodium level. We worried about how fast her sodium increased and spent significant time designing ways to slow down the sodium increase. We discharge her 2 days later with a total return of her baseline mental status.

The sixth patient did not have achalasia, rather he had diffuse esophageal spasm. The challenge we had was finding an acceptable treatment for his DES.

The seventh patient had his biopsy, and then we discharged him for outpatient radiation therapy.

The eighth patient continued to improve and was eventually discharge to a rehab facility.

The final patient was discharged after being afebrile for 48 hours. She responded well to antibiotics, but no firm diagnosis was made because blood cultures and throat cultures were negative.

I ask again – how should we judge quality for these patients? We had diagnostic problems, unusual management problems, social situations and end-of-life discussions. I believe we did a reasonable job last Monday, but I also do not believe that anyone could provide me a measurement of our quality.

This is the problem with quality measurement. We have too many diverse situations that we address each day. Often we care for unusual problems. Often we have diagnostic issues – achalasia vs. DES, etiology of hyponatremia, reason for high fever in a tonsillitis patient. We have management problems that do not easily fit into performance measures.

Any quality measures that would pertain to these 9 patients would paint an incomplete picture of our care and our tasks. We should challenge all attempts to measure something and call it quality of care. To repeat one of my favorite quotes from Donabedian

Judgments of quality are incomplete when only a few dimensions are used and decisions about each dimension are made on the basis of partial evidence.

Related Posts

1. The focus of 9 inpatients
2. How do patients define quality physicians?
3. Quality measurement – a delusion

Health News of the Day is a daily summary made from the selected links I post on Twitter. It is in a bullet points format with links to the original sources which include 350 RSS feeds that produce about 2,500 items per day.

• Phospholipase A2 receptor (PLA2R) - a major antigen in membranous nephropathy, a common form of nephrotic syndrome http://bit.ly/1a8sfK
• Study: No improvement in survival after cardiopulmonary resuscitation (CPR) in the hospital from 1992 through 2005. The overall incidence of CPR was 2.73 events per 1000 admissions http://bit.ly/xTZC5
  
  
• Blockade of renin–angiotensin system in DM1 with ACEi plus ARB did not slow nephropathy progression. Blockade of renin–angiotensin system in DM1 with ACEi plus ARB (Enalapril, Losartan) slowed progression of retinopathy http://bit.ly/kpLxy
  
  
• Celiac Disease Cases Are on the Rise: 4 times more common in the U.S. today than it was 50 years ago. Only 5% of people with celiac disease know they have it. Celiac disease rise (and allergies) blamed on hygiene hypothesis - people are exposed to fewer germs than in the past http://bit.ly/7F5vr
  
  
• American College of Cardiology shocked: CMS proposes to cut payments to cardiology services by 11% in a single year http://bit.ly/gloK4
  
  
• Orthopedic surgeons seeing a "tidal wave" of 45-64-year-olds suffering from exercise-related injuries - "boomeritis http://bit.ly/17aUbY
  
  
• Medicare May Shuffle the Deck on Doctor Payments, WSJ: http://bit.ly/3yAHr5
  
  
• Tattoo Allergy from NEJM Images in Clinical Medicine http://bit.ly/T8xz

Image source: OpenClipArt.org, public domain.

We rarely delve into politics. But if we must, Independence Day is probably a good occasion.

So over coffee and a brioche, we were reading Health Care Stories for America @ BarackObama.com. There we noticed an interesting pattern: scolding of health insurance companies is on at full steam, but no one wants to talk about the elephant in the room: Medicare. And that's where the real health care dollars are being sucked in, like into a giant black hole.

Don't believe our independent Medgadget team of doctors? Ask practically any other physician, and he or she will tell you about real horrors. How about stories where hundreds of thousands of dollars are spend on each patient that has practically hit the wall? How about pacemakers and AICDs on 90 year olds with Alzheimer's, Parkinson's or stroke? How about interventional radiology procedures, where a terminal elderly patient becomes a cushion pad for physicians? How about CAT scans, MRIs, leg bypasses, peripheral catheters, exploratory laparotomies, and hundreds of lab tests that are done every day, that often prolong more suffering than life?

We understand that there are many problems in healthcare when it comes to younger patients. We know that people lose jobs, have prior conditions, and as a result they end up losing their insurance coverage. We also understand there are abuses in the health insurance industry. But the real bulk of the societal problems is not with the people under 60, but with older patients. In other words, with Medicare. And when families, who don't have to co-pay for any medical services, are being asked to estimate the risk/benefits ratios of going ahead with a treatment, the hope itself forces them to go "all in." And that is how the tax payer's money are being spent nowadays. For all the talk over at the Health Care Stories for America, there is indeed little substance but lots of fear. And that is from the administration that has promised us hope.

And, finally, the real question. Why does the President and his team use the wrong symbol of Caduceus for his health care initiative? As we noted before, the Staff of Asclepius should be a single serpent encircling a staff, and no wings and no snake families, please. We hope you have a nice Independence Day!

Fireworks are a 4th of July tradition for just about all of us in the United States. In recent years, many child safety experts have tried to shift that tradition away...

W. L. Gore & Associates just received FDA's OK to market an updated version of the firm's GORE VIABAHN® Endoprosthesis indicated for "improving blood flow in patients with symptomatic peripheral arterial disease in superficial femoral artery lesions with reference diameters ranging from 4.0 - 7.5 mm [and] in iliac artery lesions with reference vessel diameters from 4.0 – 12 mm"

The modification is a result of the precision laser trimming technology which enables the removal of excess material at the device margin, resulting in a contoured edge. The device is the only stent-graft approved by the FDA for the treatment of patients suffering from Peripheral Arterial Disease (PAD) in superficial femoral artery (SFA) lesions and iliac artery lesions. In the US alone, as many as 12 million people suffer from PAD.

The GORE VIABAHN Endoprosthesis is constructed with a durable, reinforced, biocompatible, expanded polytetrafluoroethylene (ePTFE) liner attached to an external nitinol stent structure. The outstanding flexibility of the GORE VIABAHN Endoprothesis enables it to traverse tortuous areas of the SFA and to conform to the complex anatomy of the artery. The device was initially approved by the FDA in 2005 for treating PAD in the SFA. Later in 2007, Gore made modifications to the device which includes reducing the profile and adding a Heparin Bioactive Surface.

Product page: GORE VIABAHN® Endoprosthesis

Press release: Gore Receives FDA Approval for Modification of GORE VIABAHN® Endoprosthesis

Flashbacks Gore VIABAHN® Endroprosthesis Stent: Now Approved...

Elderly folks tend to prefer to live in their own homes as the years pass, but the potential for accidents to happen leads many to seek nursing homes or to live with family. Dana Blankenhorn at ZDNet Healthcare is reporting on technology from WellAWARE Systems (Charlottesville, Virginia) that monitors people in their homes with sensors in beds, bath tubs, and generally throughout the living space.

Dana Blankenhorn reports:

At this writing, 60 facilities have the WellAWARE system, company officials told ZDNet.

WellAWARE is offering a system of sensors that track a patient’s movement throughout their residence, comparing their activities to a baseline of normality, and alert caregivers to changes.

Noce explained how this worked recently with an 81 year old client aging-in-place in Hastings, NE:

"There was an alert that the woman had not slept for 26 hours. The woman was evasive, but we were able to be proactive, and the nurse was able to visit, knowing she hadn’t slept.

The woman finally admitted she’d been hallucinating. The nurse asked about medication, the woman said she had some, and the nurse found that one of the side effects of one medicine was hallucination. She was able to fix the situation in a day.

The patient didn’t have to do anything. The care giver was then able to provide an interaction that got correction.

More at ZDNet Healthcare...

Link: WellAWARE Systems...

Researchers from the National Cancer Institute have devised a new method to watch for the presence of the HER2 protein, a commonly expressed marker of breast cancer. As you can imagine, the implications for this technology could be immense, from doing research on pathophysiology of breast CA to developing protocols for treatment.

From the statement issued by the National Cancer Institute:

... the research team used an imaging compound that consists of a radioactive atom (fluorine-18) attached to an Affibody molecule, a small protein that binds strongly and specifically to HER2. Affibody molecules, developed by Affibody AB, Bromma, Sweden, are much smaller than antibodies and can reach the surface of tumors more easily. The radioactive atom allows the distribution of the Affibody molecules in the body to be analyzed by positron emission tomography (PET) imaging.

The research team first used the radiolabeled Affibody molecule to visualize tumors that expressed HER2 in mice. The mice were injected under the skin with human breast cancer cells that varied in their levels of HER2 expression, from no expression to very high expression. After three to five weeks, when tumors had formed, the mice were injected with the Affibody molecule and PET images were recorded. The levels of HER2 expression as determined by PET were consistent with the levels measured in surgically removed samples of the same tumors using established laboratory techniques.

To determine whether their method could be used to monitor possible changes in HER2 expression in response to treatment, the team next injected the Affibody molecule into mice with tumors that expressed very high or high levels of HER2 and then treated them with the drug 17-DMAG, which is known to decrease HER2 expression. PET scans were performed before and after 17-DMAG treatment. The researchers found that HER2 levels were reduced by 71 percent in mice with tumors that expressed very high levels of HER2 and by 33 percent in mice with tumors that expressed high levels of HER2 in comparison with mice that did not receive 17-DMAG. The researchers confirmed these reductions by using established laboratory techniques to determine the concentrations of HER2 in the tumors after they were removed from the mice.

Press release: Imaging Technique Allows Researchers to Monitor Protein Changes in Mouse Tumors

Article abstract in The Journal of Nuclear Medicine: Changes in HER2 Expression in Breast Cancer Xenografts After Therapy Can Be Quantified Using PET and 18F-Labeled Affibody Molecules....

As medical devices become smaller and more complex because of the ever increasing demand for greater precision in clinical and research applications, the need for smart materials is also on the rise. Many metal alloys are able to "remember" a specific shape they were in before transformation, the best example being self expanding coronary stents. Although memory retaining alloys are already being used in many fields of medicine, researchers from Fraunhofer-Gesellschaft are using computers to extend the application of these materials.

With the help of these simulations, the scientists have developed various objects, including a minuscule forceps for endoscopy. Normally, such micro forceps can only be created with joints. How can a component be produced that has such small dimensions, is elastic, can be thoroughly sterilized and has no joints? The computer supplies the answer: with the help of numerical simulation models, the researchers could calculate in advance the most important characteristics of the component, such as its strength and clamping force, and efficiently develop and manufacture the elastic component. "Normally, many tests with various prototypes would need to be conducted," Dr. Helm explains. "By using simulations, we can avoid producing most of these prototypes. This saves costs because the raw materials for the shape memory alloys are very expensive and are sometimes difficult to work with." In addition, the researchers can estimate through simulations how durable the modern materials are.

Full story: Design tool for materials with a memory

Researchers from Northeastern University and Harvard Medical School have developed a miniature microfluidic device that is capable of capturing endothelial progenitor cells (EPCs) from the bloodstream, in a sample of only 200 microliters of blood. Because endothelial progenitor cells move towards injuries within blood vessels, detecting their presence can lead to a diagnostic system for various vascular diseases.

From the abstract:

The surface of a variable-shear-stress microfluidic device was conjugated with 6 different antibodies [anti-CD34, -CD31, -vascular endothelial growth factor receptor-2 (VEGFR-2), -CD146, -CD45, and -von Willebrand factor (vWF)] designed to match the surface antigens on ovine peripheral blood-derived EPCs. Microfluidic analysis showed a shear-stress-dependent decrease in EPC adhesion on attached surface antigens. EPCs exhibited increased adhesion to antibodies against CD34, VEGFR-2, CD31, and CD146 compared to CD45, consistent with their endothelial cell-specific surface profile, when exposed to a minimum shear stress of 1.47 dyn/cm(2). Bone-marrow-derived mesenchymal stem cells and artery-derived endothelial and smooth muscle cells were used to demonstrate the specificity of the EPC microfluidic device. Coated hematopoietic specific-surface (CD45) and granular vWF antibodies, as well as uncoated bare glass and substrate (1% BSA), were utilized as controls. Microfluidic devices have been developed as an EPC capture platform using immobilized antibodies targeted as EPC surface antigens.

Abstract in FASEB Journal: Development of microfluidics as endothelial progenitor cell capture technology for cardiovascular tissue engineering and diagnostic medicine

(hat tip: Gizmag)

A collaborative group of German and American researchers has identified the important biochemical processes involved in the regeneration of limbs of salamanders. Nearly unique in their great ability to replace lost appendages, salamanders were thought to possess pluripotent stem cells with greater abilities to differentiate than those of mammals. Turns out that in salamanders cells located at the location where the damage has occurred keep a memory of what was in the vicinity, providing guidance for regrowth of future cells. The finding opens the possibility that scientists will be able to replicate this phenomenon in humans, leading to treatments for spinal cord injury, loss of arms and legs, and other serious injury.

From the study abstract:

During limb regeneration adult tissue is converted into a zone of undifferentiated progenitors called the blastema that reforms the diverse tissues of the limb. Previous experiments have led to wide acceptance that limb tissues dedifferentiate to form pluripotent cells. Here we have reexamined this question using an integrated GFP transgene to track the major limb tissues during limb regeneration in the salamander Ambystoma mexicanum (the axolotl). Surprisingly, we find that each tissue produces progenitor cells with restricted potential. Therefore, the blastema is a heterogeneous collection of restricted progenitor cells. On the basis of these findings, we further demonstrate that positional identity is a cell-type-specific property of blastema cells, in which cartilage-derived blastema cells harbour positional identity but Schwann-derived cells do not. Our results show that the complex phenomenon of limb regeneration can be achieved without complete dedifferentiation to a pluripotent state, a conclusion with important implications for regenerative medicine.

Full story: Scientists: Salamanders, regenerative wonders, heal like mammals, people....

Abstract in Nature: Cells keep a memory of their tissue origin during axolotl limb regeneration

Images: Top: Axolotl salamander by cataclico; Side: Green nerve cells cluster around a growing nerve in this cross-section of a regenerating limb. D.Knapp/E.Tanaka.

Nephros, Inc., out of River Edge, New Jersey, received FDA approval for the firm's Dual Stage Ultrafilter system. The device is designed to provide redundant filtration for purifying of dialysate fluid and bicarbonate solution.

From the product page:

The Nephros DSU has a 0.005 micron filter pore size designed to remove a broad spectrum of bacteria, viral agents and biological toxins. These toxins include salmonella, hepatitis, HIV, Ebola viruses, legionella, fungi and e-coli. The DSU removes these harmful substances more effectively than other microwater filters currently on the market.

The Nephros DSU's unique design and materials ensure high flow rates and long life. The true redundant design provides the highest confidence in filter integrity and performance. The Nephros DSU is a truly cost effective, simple and compact means to reliably produce on-site ultrapure water where you need it, when you need it.

Product page: Dual Stage Ultrafilter...

Nephros DSU brochure...

Press release: Nephros Receives 510k Approval for Dual Stage Ultrafilters...

The U.S. Consumer Product Safety Commission has announced the recall of another 400,000 Simplicity Drop Side Cribs because the 'crib’s plastic hardware can break or deform, causing the drop side...

Was it Robert Wachter or Myra Rosenbloom? You decide.

Background in Today's Hospitalist.

Primary Care Wins, Imaging Loses, Under New CMS Proposal – ht to Vinny Arora who retweeted AbbieCitron – Twitter does increase the speed at which I learn about important articles.

Primary care physicians are cheering—and radiologists are jeering—a new CMS proposed change to the Medicare Physician Fee Schedule that will cut reimbursements for imaging services by as much as 30% and use the savings to raise reimbursements for primary care by as much as 8%.

“I am surprised. We all kind of knew this sort of thing was coming, but until you see it in writing you don’t believe it,” says Ted Epperly, MD, president of the American Academy of Family Physicians. “We’ve been there before and never saw it. Putting it out now in the heat of the debate is a big deal. It sends a strong message.”

“I’m impressed that CMS is actually doing stuff to reformulate the system toward primary care. Of course, the devil is in the details and we will see what the final product looks like, and it’s not a total fix, but it’s a step in the right direction,” he says.

The AMA has always argued that enhancing primary care should not come at the expense of other physicians.  I have remained skeptical, because they have benefited at the expense of family physicians and non-procedural internists.

I like much of what CMS is proposing:

CMS is also proposing to:

• Remove physician-administered drugs from the definition of “physician services” in anticipation of enactment of legislation to provide fundamental reforms to Medicare physician payments. While the proposal will not change the projected update for services during 2010, CMS projects that it would reduce the number of years in which physicians are projected to experience a negative update. AMA President J. James Rohack. MD, called the proposal “a major victory for America’s seniors and their physicians.”
• Implement a mandate in the Medicare Improvements for Patients and Providers Act of 2008 that suppliers of the technical component of advanced imaging services be accredited beginning Jan. 1, 2012 by designated accrediting organizations. The accreditation requirement would apply to mobile units, physicians’ offices, and independent diagnostic testing facilities that create the images, but would not apply to the physician who interprets them.
• Implement provisions to promote improvement in quality of care and patient outcomes through revisions to the Electronic Prescribing Incentive Program and the Physician Quality Reporting Initiative. Professionals or group practices that meet the requirements of each program in 2010 will be eligible for incentive payments for each program equal to 2% of their total estimated allowed charges for the reporting periods. CMS is proposing to simplify the reporting requirements and is also proposing a new process for group practices to be considered successful electronic prescribers.
• Refine Medicare payments to physicians, which are expected to increase payment rates for primary care services. The proposals include an update to the practice expense component of physician fees. For 2010, CMS is proposing to include data about physicians’ practice costs from a new survey, the Physician Practice Information Survey, designed and conducted by the AMA.
• Stop making payments for consultation codes typically billed by specialists at a higher rate than evaluation and management services. Physicians will instead use existing E/M service codes when providing these services. The resulting savings would be redistributed to increase payments for the existing E/M services.
• Increase the payment rates for the so-called “Welcome to Medicare” visit to be more in line with payment rates for higher-complexity services.
• Refine how Medicare recognizes the cost of professional liability insurance in its payments. These changes would have a modest impact, but they will promote payment equity by redirecting the portion of Medicare’s payment for professional liability insurance to those physicians that have the highest malpractice costs.

Taken together, CMS says refining the practice expenses, eliminating payment for the consultation codes and revising the treatment of malpractice premiums would increase payments to general practitioners, family physicians, internists, and geriatric specialists by between 6% and 8%.

I have not read the CMS proposal, but this morning it looks very interesting.

Related Posts

1. Primary care payment – is win-win possible?
2. Universal health care will require fair pay for primary care
3. Finding enough primary care

Our brains are obviously hard-wired to love food.  For many years, scientists have been trying to unravel the mystery of why we go all ga-ga over fresh-baked chocolate chip cookies, for example.  If we could figure out — and even control — the neuroscience of appetite, just imagine what that would do for combating obesity, [...]

Are you going somewhere this fourth of July? It’s the biggest holiday in the US and that means lots of time in the family car on long road trips! While many things can happen on a family road trip, healthy eating usually isn’t one of them…. well, until now.

SUBWAY created its restaurant locator (http://www.subway.com/Applications/locator/index.aspx) where you can spot various SUBWAY locations along your route so you don’t end up eating less-healthy greasy burgers or gas station food. And the restaurant locator is world-wide so wherever you go, you’ll find some SUBWAY restaurants to choose healthy foods from!

And, in the spirit of road trips, SUBWAY teamed up with National Geographic for the “Taste for Adventure” sweepstakes. Starting July 1, kids age 6-14 can tell about their most exciting journey (past, present or future dream adventure) in 100 words or less, for a chance to win an unforgettable Alaskan Family Adventure! Kids can enter online at kids.nationalgeographic.com (beginning July 1) or www.Subwaykids.com (beginning July 6) OR in-store!

So to start the ball rolling, SUBWAY sponsored a give-away at Genetics and Health! One winner will get the chance to win a SUBWAY car kit*! The kits will include: an insulated lunch tote for healthy snacks, a $10 SUBWAY gift card, car games, etc. (approximate value = $35-40).

 

 

Check out the contest rules after the cut…

 

For a chance to win a SUBWAY car kit*, briefly share in the comments your most recent family road trip!

• One entry per person per day.
• It’s open to residents of the US only.
• Contest ends 11:59 midnight EST on July 14, 2009 (Tuesday)
• One winner will be randomly chosen and announced via blog and email the week after.
• If the winner does not reply within 3 days, he/she forfeits her winnings and an alternate entry will be chosen.
• REMINDER #1 : In previous contests, I have had several winners forfeited for failure to reply to my emails.  Please make sure your settings don’t put my email into the junk folder, otherwise you’ll have no idea you won. Better yet, please check this blog for the winners’ list after the contest ends. Best bet, come back often and stay a reader!

 

Have fun and stay safe this summer!

*NOTE: Colors and exact games/accessories of the SUBWAY car kit may vary but each kit is valued at approximately $40 including the SUBWAY gift card”

Image: Subway

Post from: Genetics & Health

Yanko Design blog is featuring the work of Elijah Stillson who offers a new design idea for a respirator. Although, when wearing this thing, one would be the most attractive person in a crowd of evacuees, let's hope the device can seal around the face to stay tight with this design.

Link: Respirator Mask Design by Elijah Stillson

(hat tip: Gizmodo)

An English gentleman, possibly skeptical of the offerings provided by the National Health Service (NHS), decided to perform his own circumcision at home. Apparently not aided by anything other than some ethanol, the patient/physician brought a pair of nail clippers to the surgical theatre/kitchen sink. Inevitably something went terribly wrong and medics had to be brought out.

The Telegraph quotes one from the rescue team:

"This is something we would advise men never to attempt," a medic said, "The results can be quite horrific and long-lasting and have quite an affect on a man's sexual performance.

"Using a pair of nail clippers must have caused excruciating pain, even if he had had a few drinks beforehand."

More from The Telegraph...

Image: mokolabs

Brainsway Ltd. out of Jerusalem, Israel, a company we've been covering over the last few years, has received local approval to conduct clinical trials of its deep transcranial magnetic stimulation (TMS) as an aid in quitting smoking. The drastic approach is to be tested on about 100 lung cancer patients that have not been able to quit using other methods.

More from Globes Online...

Flashbacks: Magnetic Brain Stimulation for Cocaine Addiction, Multiple Sclerosis?; Positive Results Reported for Deep TMS H System For Depression; Deep TMS Technology by Brainsway

Crospon, out of Galway, Ireland, recently received Frost & Sullivan's 2009 European Gastroenterology Technology Implementation of the Year Award for the Endoflip device. The Endoflip delivers a balloon catheter to the gastroesophageal sphincter, a junction between the esophagus and stomach, and can test the strength of the muscles controlling its closure. Already approved in the EU, the company is seeking FDA's approval for the US market.

From the manufacturer:

Crospon has addressed the need for a GERD-focussed diagnostic platform by developing an integrated solution which facilitates real-time imaging of the lower esophageal sphincter in less than 10 minutes. The EndoFLIP® system constitutes a set of 16 electrodes that sit within a balloon catheter which is attached to a data recorder with a touch screen. This series of electrodes is capable of measuring resistance or impedance to calculate cross-sectional areas at different points along the balloon. At the commencement of the procedure, the deflated balloon catheter is attached to a prefilled syringe, which is inserted into the syringe pump on the front of the EndoFLIP® tool. Subsequently, the deflated balloon is then passed trans-orally or trans-nasally to the gastroesophageal junction whereby it permits a challenge test to the lower esophageal sphincter to determine its functionality.

The scientific principle behind EndoFLIP®’s implementation is impedance planimetry. This is a technique that can measure cross-sectional area electrically which in turn enables 16-slice display images. This display shows the changes in the estimated diameters of sphincteric regions in the body in real time, thereby permitting a real time image of the geometry in vivo of the human esophagus to be obtained. Crospon has submitted an application to the FDA for EndoFLIP®’s clearance in the US market. The company has already received CE mark certification from the National Standards Authority of Ireland.

Video below fold demonstrating the placement of the device:

Press release: 2009 European Gastroenterology Technology Implementation of the Year Award...

More literature about the device...

Scientists from the Max Planck Institute of Colloids and Interfaces have developed a new process to put together nanoparticles directly in the environment that is being studied. Additionally, this technique has led to the creation of tiny "light bulbs" that can be attached to specific proteins, opening a new modality for visualizing biochemical processes.

From a statement by the Max Planck Society:

"We used the fact that cells represent a closed reaction container as a model for the synthesis of nanoparticles," says Rumiana Dimova. Her group at the Max Planck Institute of Colloids and Interfaces studies membranes - the cell envelope. The scientist and her colleagues form bubbles that are around 50 micrometres in size from lecithin membranes, which are similar to biological membranes. Like cells, membrane bubbles - or vesicles as scientists refer to them - also provide a closed reaction container. The scientists load the membrane bubbles with one of two reactants for the nanoparticles.

From this point, the researchers have developed two different sets of protocols. In one case, they produce bubbles loaded with one of the two reactants, sodium sulphide or cadmium chloride. The scientists then bring the bubbles with the different loads together and fuse two vesicles to form a bigger vesicle - this is done by subjecting the bubble cocktail to a short but very strong electrical pulse. The electric shock fuses the membranes of two adjacent bubbles.

In many cases, this results in the fusion of two bubbles containing different reactants. These then react to form cadmium sulphide, which is not water soluble and thus precipitates in the form of nanoparticles. "Because the reactants are only present to a limited extent in the fused bubbles, the particles only grow to a size of four nanometres," explains Rumiana Dimova. The scientists were able to track the entire process directly under the microscope because they had added different fluorescent molecules to the membranes of the differently loaded vesicles. The researchers were also able to see the nanoparticles forming as the particles shone like tiny lamps.

In the second process, the researchers only produce vesicles with one of the reactants. When the vesicles have formed, unlike in the first procedure, the researchers do not remove them from the production chamber. Instead, the bubbles remain attached to their substrate via small membrane channels, like balloons tied to strings, and stand in a solution that is the same as the one inside them. The researchers working with Rumiana Dimova then altered this situation: they substituted the solution with the first ingredient for the nanoparticles with a second component. This causes no change inside the vesicles at first. The second ingredient only creeps gradually between the substrate and membrane into the channel and to the vesicle. In the vesicle, where the other ingredient is already waiting, the nanoparticles grow again - this time to a size of 50 nanometres.

Press release: Making nanoparticles in artificial cells...

Eshel Ben Jacob, a professor of physics at Tel Aviv University, beautified photos of bacteria growing in Petri dishes with a bit of color and shading to create an amazing collection you can browse yourself.

Here's what the artist/scientist tells Medgadget about the works:

They illustrate the coping strategies that bacteria have learned to employ, strategies that involve cooperation through communication. These selfsame strategies are used by the bacteria in their struggle to defeat our best antibiotics. Thus, if we understand the mechanisms behind the patterns, we can learn how to outsmart the bacteria - for example, by tampering with their communication - in our ongoing battle for our health.

In a sense, the strikingly beautiful organization of the pattern reflects the underlying social intelligence of the bacteria. The once controversial idea that bacteria cooperate to solve challenges has become commonplace, with the discovery of specific channels of communication between the cells and specific mechanisms facilitating the exchange of genetic information. Retrospectively, these capabilities should not have been seen as so surprising, as bacteria set the stage for all life on Earth and indeed invented most of the processes of biology. As we try to stay ahead of the disease-causing varieties of these versatile creatures, we must use our own intelligence to understand them. These images remind us never to underestimate our opponent.

Link: Theories of Mind Art Gallery...

A team of Canadian researchers analyzed the air traffic patterns during March and April of this year, looking for correlation between departure/arrival cities of passengers and the spread of H1N1 swine-origin influenza. Turns out that the two are closely correlated and confirm that airports are gateways of pathogens as well as vacationing tourists.

Our analysis showed that in March and April 2008, a total of 2.35 million passengers flew from Mexico to 1018 cities in 164 countries. A total of 80.7% of passengers had flight destinations in the United States or Canada; 8.8% in Central America, South America, or the Caribbean Islands; 8.7% in Western Europe; 1.0% in East Asia; and 0.8% elsewhere. These flight patterns were very similar to those during the same months in 2007 (see Fig. 1 in the Supplementary Appendix). We then compared the international destinations of travelers departing from Mexico with confirmed H1N1 importations associated with travel to Mexico, and we found a remarkably strong degree of correlation. Of the 20 countries worldwide with the highest volumes of international passengers arriving from Mexico, 16 had confirmed importations associated with travel to Mexico as of May 25, 2009. A receiver-operating-characteristic (ROC) curve plotting the relationship between international air-traffic flows and H1N1 importation revealed that countries receiving more than 1400 passengers from Mexico were at a significantly elevated risk for importation. With the use of this passenger threshold, international air-traffic volume alone was more than 92% sensitive and more than 92% specific in predicting importation, with an area under the ROC curve of 0.97.

Letter to NEJM: Spread of a Novel Influenza A (H1N1) Virus via Global Airline Transportation

---is fast approaching. I've told you about it here and in several other posts. I'm signed up and ready to go. This is a rich learning experience for me, as well as my annual battery-charging.

The conference should be of benefit to anyone interested in evidence based cost effective cardiology, cutting edge advances and diagnostic skills. There will also be some updates on cardiovascular genetics, VTE and peripheral vascular disease. The course is appropriate for physicians (IM, FP, hospitalists, cardiologists), physician extenders, nurses and allied health care professionals.

Why attend?

This conference provides a unique opportunity to interact one on one with faculty. The quiet, spectacular beauty of the setting enhances the learning experience. Before the American College of Cardiology cut its CME conferences several years ago this was the College's most popular extramural activity, year after year, during its entire run. The PharmaScolds are trying to shut the meeting down, so this may be your last chance!

I'll be posting additional updates, but register as soon as possible, as accommodations have filled up fast in previous years. If you have questions about the conference I'd be glad to talk to you. Just let me know in the comments or via direct email.

Blogging colleagues, if you plan on attending let me know so we can arrange a confab over an adult beverage with a spectacular mountain view at the Blue Heron lounge.

The final course brochure and registration form is here.

I’m taking a cue from my buddy Scott Johnson and other bloggers, and enjoying a look back at what I was on about here a few years ago, via the WayBack Machine.  Here’s what DiabetesMine roughly looked like back in 2005. Wow! In the process, I stumbled on the following post, from April 2005, that [...]

Research study and editorial in JAMA.

Do you know respiratory bronchiolitis-associated interstitial lung disease (RbILD) from bronchiolitis obliterans with organizing pneumonia (BOOP)? This review helps clarify the terminology.

Tylenol (acetaminophen) is in the news, but not because of a recall or any new drug warnings. Instead, health experts are concerned about the many accidental Tylenol overdosages that affect people...

Will a new prenatal genetic test create designer babies? That’s one of the questions raised as news that a universal embryo test could be available next year.

The current method for prenatal genetic testing involves either amniocentesis or chorionic villus sampling (CVS) to get embryo fluids or placenta cells from a pregnant woman’s abdomen. The placenta or placental fluids contain cells generated by the fetus. These cells are used to identify chromosomal abnormalities that can affect a baby’s survival or capacity at birth. Prenatal genetic tests are mainly used to provide information to the parents about their unborn child’s genetic condition before birth, so they can make informed decisions and manage the pregnancy better.

Unfortunately, the current methods are invasive and tests can take up to a month before results are known. And these tests don’t provide information about other genetic conditions that don’t show up on chromosome changes.

Today, a BBC report reveals that a “universal embryo test” may soon provide information on 15,000 genetic conditions… at least and for the meantime, in theory. The test is called “Karyomapping” which looks for abnormalities in the fetus’ DNA by comparing his genome with the parents. The technique maps all of the fetal chromosomes, so it can check for any gene before the baby is born, or even years after birth. The technique can potentially identify non-life-threatening genetic conditions, and so open a possibility for creating “designer babies”. Hence, once the test is approved for use, only a number of conditions – usually life-threatening -  will be allowed to be tested using karypmapping. For now.

 

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Post from: Genetics & Health

The positive and negative predictive values for central pulmonary artery obstruction were good in this study:

Troponin values were elevated in 20 (19.2%) of 104 patients (95% confidence interval [CI], 11.6-26.8) with a mean cTnI concentration of 0.38 ± 0.44 μg/L. Elevated cTnI value had a significant correlation with main pulmonary arteries involvement using the modified Computed Tomography Obstruction Index score (P = .0001). Elevated ED cTnI value had 53.8% (95% CI, 37.6-66) sensitivity and 92.3% (95% CI, 87-96.4) specificity, 70% (95% CI, 49-86) PPV, and 85.7% (95% CI, 80.7-90) NPV for predicting main pulmonary artery obstruction on CT. Increased cTnI values were highly correlated to intensive care unit admission of patients with PE (RR, 12.83; 95% CI, 3.87-42.4).

The evidence in favor of cardiac biomarkers in the ER evaluation of suspected PE is mounting.

When I was a guest on cancer-patients podcast last week, the hosts asked me if we PWDs don’t get frustrated: cancer seems to have all the big celebrities behind it, and make all the big headlines. Does it ever bother your community that diabetes doesn’t get that level of attention? I was a bit dumbfounded. [...]

Fee for service is said to be a major cause of the high health care costs that we are told must be brought under control to save the economy.Dr. Donald J. Boudreaux,Chair of the Economics Department at George Mason University, argues that is not correct.Rather a major cause is the fact that much of medical care is paid for with someone else's money. Go here to read his entire commentary.

Not surprisingly, the FDA has found a sample of prepackaged Nestlé Toll House refrigerated cookie dough that was contaminated with the E. coli O157 bacteria. Previously, the FDA strongly suspected...

Don’t forget the association. It can be an aneurysm or a pseudoaneurysm, can occur as a new aneurysm or infection of a pre-existing one, and is associated with certain predisposing conditions. Species associations, according to the brief review, tend to be enteritidis and typhimurium. The article references several other reviews.

This article in the American Journal of Medicine explores some of the reasons. Repeated copying and pasting of other notes and template generated electronic clutter are two. Another underappreciated aspect is loss of the power of clinical narrative:

Another more insidious consequence of the copy-and-paste function has been the loss of the narrative. Because charts have become capacious warehouses of disorganized, irrelevant, or erroneous data, the story of the patient and the patient's illness is no longer easy to read or likely to be read. In a most compelling and perhaps unintended way, we are witnessing the “death” of the health record narrative, as many of us have known it. Others also speak of the loss of narrative in electronic health records, and with great concern because narratives form the basis of clinical decision making.

Daily documentation of the patient's trajectory, in prose, even when stripped of overt emotional content, is not just educational. It is humanizing.

I have yet to encounter an electronically generated note that effectively tells a patient’s story.

The 27,000 Americans confirmed to have the swine flu is just the tip of the iceberg, the CDC revealed this weekend. Instead, more than one million Americans have already been infected with the A (H1N1) influenza virus, or swine flu. And it’s not letting up just yet.

One million Americans infected with (H1N1) swine flu virus.

“The novel H1N1 influenza is continuing to spread here in the United States and around the globe.  What we’re seeing is varying by region in the United States and in different countries.  The key point is that this new infectious disease is not going away.  In the U.S., we’re still experiencing a steady increase in the number of reported cases. (CDC)

Of the reported 27,717 lab-defined cases, 127 have died. Most of those who have gotten sick were people under 50 years old, and the median age of those who died is 37 years old, which too young for someone to be dying of flu. And according to Anne Schuchat of the CDC, there may actually be more than one million cases of the swine flu in the US, but the agency is “not tracking every single one of them”.

Although the vast majority have been very mild cases of swine influenza, having that many number of people sick is still a grave concern. At any given day, that’s the number who can also transmit the virus to someone else. And unfortunately, a flu virus can be transmitted anytime between one day before any symptoms appear to a week after.

I had a scary bout with the flu last week when my 18-month old had a 102-degree fever over three days and then started to have chills that night. We rushed him to the emergency room at 2 a.m. and asked for a flu test. That God he was negative for any virus, but it was scary because I couldn’t know for certain what his symptoms were about.

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Post from: Genetics & Health

This post is a reply to a comment made on one of my earlier postings that inquired about the single payer option for U.S.health care or at least what were my thoughts.

I believe the major issue is whether the single payer system that we may eventually end up with allows a parallel system of private care as is the case in Great Britain or if government forbids people to spend their own (or insurance) money for services not provided by the single payer government plan, as is the case in Canada. In the later arrangement the patient's life and health is literally in the hands of the government and without the private option there is no practical appeal to the edicts of the bureaucracy that control the expenditures of the single payer system. Of course, in Canada not infrequently folks go south for health care that is denied or so delayed that it is for practical purposes denied. Also, recently there is an interesting and encouraging move to some elements of private care becoming available in Canada (see here). As the U.S. seemingly is moving to more government involvement in health care, there seem to be a directionally opposite move in Canada where they have had years to see how well or badly their hyper-egalitarian health care system works in the real world.

We have had Medicare since 1965 and it is not going away.The best we can hope for after the re-working of the medical care system comes to pass is for the people to be able to purchase health care denied by the government system without having to travel overseas. ( Maybe the private care movement in Canada will be mature enough by then so we can go there for care.)

An interesting twist on this general topic is the suggestion made in a WSJ October 2008 editorial to "allow"seniors to opt out of Medicare entirely, not just Part B.See here for a discussion of how that might be good for some and harming none, something economists seem to refer to as Pareto Optimal.Currently if someone wants to opt out of Part A he will loose Social security benefits.

I did not realize that until recently.Here is the rule in the words of the government:

"Individuals entitled to monthly benefits which confer eligibility for HI ( hospital insurance,Part A of Medicare) may not waive HI entitlement. The only way to avoid HI entitlement is through withdrawal of the monthly benefit application. Withdrawal requires repayments of all RSDI and HI benefit payments."
h/t to Junkfood Science)

This was not the way the Medicare law was written. You have to wonder what prompted the SS administration to add on this rule. Why would they object to someone opting out of Part A? It would only be a saving for Social Security.

The terms one tier and two tier are sometimes used to distinguish between the systems exemplified by the British and the Canadian systems. One Tier would be Canada and two tier would be Great Britain. In this article in the Archives of Internal Medicine there is a discussion about the ethics of the two systems. Interestingly, one of the authors who supported a two tier system from a practical and ethical point of view is Dr. Ezekiel Emanuel who is the brother of Rohm Emanuel.I hope Rohm will give some thought to his brother's views.

Considering what I am about to write, I feel a little guilty about the post headline here. But these sensational headlines are just the point: the media is abuzz the last few days with the possibility that Lantus insulin “may be linked” to cancer. The rumors started late last week, when the media got wind that [...]

The federal court stepped in to ban the genetically modified alfalfa produced by Monsanto Co., pending a thorough review of the crop’s impact on the environment.

The ruling by the 9th U.S. Circuit Court of Appeals on Wednesday leaves Creve Coeur-based Monsanto with two options. It can appeal the case to the U.S. Supreme Court or hope for regulatory approval after the Agriculture Department completes a comprehensive environmental review. (stltoday.com)

Environmental groups and alfalfa-seed farmers sued the government in 2007 over its decision to release GM alfalfa without reviewing how the crop can potentially affect the environment. According to this news, the case marks the “first time a thorough environmental review has been required for regulatory approval of a genetically modified crop”.

And I am surprised that there wasn’t a thorough review in the first place, before Monsanto even invested acres of land on planting GM alfalfa. Isn’t it breeding 101 to test the impact of introduced crops or animals? I mean, the US Customs is so strict about bringing live plants, fruits and animals on board planes from overseas, and yet the Department of Agriculture did not have measures in place to test for this new technology.

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Post from: Genetics & Health

It can be frustrating, both for pediatricians and parents, when a vaccine that a child is scheduled to receive is unavailable. In addition to not being fully protected against a...

I'm all over health care variation and non-evidence based medicine (N-EBM) these days. They're hot topics because of their close ties with the current health care reform debate.

If you want some entertainment on the subject, and can stomach a little demagoguery and name calling about greedy cardiologists and pigs running the AMA by all means check out this post by Doug Bremner, M.D. If you want something factual look elsewhere.

Bremner's post is so over the top and patently absurd one wonders whether it even merits a serious response, but, evidently, some people take Bremner's blog seriously. Besides, all I have to do to smack it down is cite some simple facts, so here goes.

He starts with this:

I just found a way to save 25 billion dollars a year for President Barack Obama’s healthcare plans. That is to cut out angioplasty, for which multiple studies, including one in the June 11 edition of the New England Journal of Medicine. The mounting evidence that angioplasty is not more effective than medication treatment alone in preventing heart attack and death in people with heart disease doesn’t stop doctors from performing them.

Wrong, wrong, wrong, Dr. Bremner.

First, I'll give him the benefit of the doubt and assume he's not really talking about angioplasty but rather coronary stenting. Angioplasty as the principal coronary intervention is seldom performed anymore. In the NEJM study he cited almost all the PCI patients underwent some form of stenting.

Concerning stenting, most are not done in patients addressed in that NEJM study or the other landmark trial with similar findings, the COURAGE trial. In fact, patients with stable angina represent less than a third of those who get stents nowadays.

Let's pick apart Bremner's statement a bit more---

The mounting evidence that angioplasty is not more effective than medication treatment alone in preventing heart attack----

Huh? Cardiologists have known for over a decade that revascularization doesn't prevent heart attacks. No one is promoting it for that indication. Where does Dr. Bremner get his “information?”

Let's parse it a bit more (my italics):

The mounting evidence that angioplasty is not more effective than medication treatment alone in preventing heart attack and death in people with heart disease doesn’t stop doctors from performing them.

Nonsense. The COURAGE trial certainly did stop doctors from performing them in patients with stable angina, almost immediately:

ResultsThere was a significant increase in anti-ischemia medication use prior to catheterization referral following the COURAGE trial (mean = 1.31 [SD 0.83] medications pre-COURAGE, mean = 1.54 [SD 0.84] medications post-COURAGE, P = 0.012). Among 217 patients with coronary disease on catheterization, treatment with medication rather than percutaneous or surgical revascularization increased after COURAGE (11.1% pre-COURAGE vs 23.0% post-COURAGE, P = 0.03). There was also a significant decrease in referral volume following the COURAGE trial (3.12 referrals/day pre-COURAGE vs 2.51 referrals/day post-COURAGE, P = 0.034).

ConclusionsThe COURAGE trial immediately impacted the management of stable angina. Catheterization referral volume decreased, medication use increased, and the use of medical therapy rather than revascularization increased among patients with coronary disease.

And, there was this from Heartwire:

Use of coronary stents, including drug-eluting stents (DES), "dropped sharply" in April, the Wall Street Journal reports, citing a marketplace report conducted by Millennium Research Group in 140 US hospitals [1].

According to Journal reporter Keith J Winstein, doctors did roughly 71 200 stenting procedures in April: 10% less than in March and 15% less than the previous year. Physicians believe that drop, writes Winstein, is "an unusually quick response" to the COURAGE trial, presented at the ACC 2007 meeting in March. In COURAGE, stents (primarily bare-metal stents) were no better than optimal medical therapy at preventing future death or MI in people with stable coronary artery disease.

So here's the bomb in Bremner's post:

But I’ll give the reason why they still perform 1.2 million of these procedures every year. It is pretty simple really. Greed.

The moral preening and finger pointing that goes on in our profession is astounding.

Evidence, please, Dr. Bremner.

Perhaps the most concerning problem with Dr. Bremner's post is that he conflates stenting for stable angina with it's real evidence based use, which is in patinets with acute coronary syndromes. Emergent PCI for patients experiencing acute STEMI has been shown over and over again to save lives, save ejection fractions and get people back to work. Let's hope some misguided folks in Washington don't deprive them of it. I personally believe the doctors taking care of patients who know what they're doing should be the ones responsible for critical appraisal of best evidence, not some policy wonks from afar. See why?

As much as I liked Gawande's New Yorker article I'm having increasing reservations about the accuracy of his assertions, as I suggested here. I think the comment thread from Thursday's post deserves reposting:

Clinton said...
Just some fact-checking.
St. Louis County's Medicare $/beneficiary = 8,306.

Not sure if Wikipedia is a great reference, especially lacking an independent citation, but St. Louis does not show up as #3 (that spot belongs to Starr County, TX.)

Hidalgo County hits the list at #22, while St. Louis doesn't even hit the lowest 100 list. Something isn't quite right with Gawande's statistics. Maybe he is going off of a different set of measures than lowest income per capita or median household income?

http://www.dartmouthatlas.org/interactive_map.shtm
http://en.wikipedia.org/wiki/Lowest-income_counties_in_the_United_States

R. W. Donnell said...
Clinton,
The figure you cite is identical to his. That's for St. Louis County, as he said. The problem is, St. Louis County is not among the poorest regions in the nation by any metric or any stretch of the imagination. The City of St. Louis (which is, I repeat, NOT in St. Louis County) may be. He doesn't seem to have any idea of what the cost per enrollee is for the City of St. Louis, but that's what he needs to cite if he wants to make his point about poverty and Medicare expenses.

My guess would be that the cost would be high in the City of St Louis. I think care is pretty fragmented and under served. Most of the hospitals (aside from ones affiliated with the two med schools) have moved to the burbs, so the picture there is pretty atypical.

I don't consider Wikipedia a very authoritative source but I know St. Louis is a city without a county from personal familiarity with the area.

Raises even more questions about his fact checking.

Antiplatelet agents, but not anticoagulants, were associated with cerebral microbleeds in this study. While that may seem surprising at first glance it actually makes sense. Intracranial microbleed is a disease of the elderly, and is related to amyloid angiopathy in the case of lobar bleeds and hypertensive or atherosclerotic small vessel disease in the case of subtentorial bleeds. Following a tiny break in a blood vessel your first defense against such hemorrhage is the platelet plug, not the coagulation proteins. Although warfarin is known to be associated with spontaneous intracranial hemorrhage this study challenges our thinking about antithrombotic therapy in the elderly.

Amyloid angiopathy and associated hemorrhage are related in a complex way to the APO E genotype.

Medscape CME here.

A final run-through of our 150+ amazing submissions in this year’s DiabetesMine Design Challenge reveals some of the “prettiest” entries — those that obviously come from the world of artful design rather than medical utility. And why shouldn’t more medical devices be more aesthetic?!   PicoSulin mini insulin pump - weighs just 2 oz. and uses and [...]

I’m so excited about July’s episodes on NOVA ScienceNOW! The series has a great line-up of genetic and other science segments that can hold anyone’s interest. And it’s perfect if you want your kids to get some brain-juice flowing through the summer.

So beginning June 30 and every Tuesday night at 9pm ET/PT, NOVA at PBS will feature “Super-Science Tuesdays” with new stories from genetics (!!), technology, science and medicine. Check out a couple of these episodes -

June 30 (Tuesday) Episode 1.

Remember the anthrax scare after 9-11 that took months to solve? Well now scientists are using genetic “fingerprinting” to trace the source of the strain, and other microbes responsible for epidemics or poisonings.

And then, there’s a secret “diamond farm” that engineers artificial diamonds that can fool even the diamond experts! I wonder if it’s cheaper too?

July 7 (Tuesday) Episode 2.

Watch a lady scientist study the cannibalistic behavior of the Australian redback spider! And then check out a telescope that’s looking for “Planet Earth 2.0”. On the genetics segment, a scientist hunts for the elusive autism genes.

July 14 (Tuesday) Episode 3.

Two new drugs are now approved by the FDA that can potentially help children with muscular dystrophy, a genetic condition that weakens the muscles. But could these drugs also be abused by athletes?  And also dinosaurs! Or in this episode, how they might have been wiped out by parasitic pandemics.

July 21 (Tuesday) Episode 4.

Picky eaters, anyone? It looks like a scientist is about to show that receptors on taste cells are not only found in the mouth! And… we know sea lions are smart, but can walruses really talk? Good time to find out.

July 28 (Tuesday) Episode 5.

They’re called “moon smashers”, and NASA scientists are going to unleash them on the moon’s surface to see understand more about building a permanent base on the moon. Plus, the songs of zebra finches may help us understand human language. Scientists think the way finches learn to sing is the same way that babies learn to speak. How cool is that?

 

 

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Post from: Genetics & Health

H/T to DB for pointing me to this follow up article by Atul Gawande concerning his earlier New Yorker piece on health care costs.

Here he elaborates and provides more data in response to objections and questions concerning his original article. He also re-emphasizes that it’s all about organization and leadership and gives another example, Scott and White Hospital in Temple, Texas which is part of an integrated medical group in many ways like Mayo Clinic. Despite having, purportedly, more physicians per capita than any other community in the U.S., Temple Texas has high quality scores and low costs.

One quibble. In answering the point about McAllen’s poverty as a possible driver of utilization he says:

By any measure, McAllen’s poverty and poor health fails to account for its differences from El Paso. St. Louis is located in another county that is just as poor as McAllen (it is the third-poorest county in the U.S.). Its cost per Medicare enrollee? $8,306.

St. Louis is not located in a county. It is an independent city. The surrounding St. Louis County, particularly its western aspect, is very wealthy. This leaves me wondering how well he checked his other “facts.” It is not clear whether his figure of $8,306 per enrollee represents St. Louis or St. Louis County. The demographics and culture are as different as night and day. (I grew up in the area).

It is summer, the time of year when our diabetes is most visible, at least for those of us who wear insulin pumps. This Tuesday, for the first time I can remember since starting on the OmniPod system, I wore a bikini. My usual modus operandi has been to place the pod on my belly all [...]

Indian scientists are on their way to creating a different kind of transgenic fish. This fish, a popular variety of carp known as rohu, matures twice as fast and bears more eggs than the regular carp. Extensive tests need to be conducted on it before scientists can release it for production. Not needed, say the creators because it’s not the the usual kind of transgenic organism.

Genetically modified plants or animals are known to have genomes bearing foreign genes. One such example is the GloFish, which has a set of genes from other organisms that have been combined to create a new set of genes that make the fish glow. Another example is the transgenic maize Bt corn, which has a bacterial gene inserted into its genome.

Transgenic organisms like these need to be tested for bio-safety and ecological impact in the field because of the potential risk that these foreign genes may have.

But scientists at the Centre for Cellular and Molecular Biology in New Delhi say their carp is different. The carp is auto-transgenic, meaning the inserted genes are modified using inherent carp genes from within the species. There are no “foreign genes” to speak of and so there is no need to test its biosafety.

India’s department of biotechnology will test the fish but a scientist cautiously commented that there is no likely toxic protein produced from this modified carp.

via: Livemint

Image: Flick

Post from: Genetics & Health

This totally sounds like an urban legend and should really be considered as such. But, it is newsworthy.

According to a quote through the Examiner, Russian scientists secretly warned Prime Minister Putin about a “critical link” between the H1N1 Influenza virus and genetically modified amylopectin potatoes which are sold in Western countries as french fries.

The report goes on to say that the genetically changed protease enzyme in the potatoes is so stored in the host cells (that’s us, humans who eat the fries) that our cells’ contact with an H1N1 virus creates an explosion in the viral envelope. The protein causes an acidic environment for the virus that explodes its envelope and releases the H1N1 RNA and core proteins into the host cell.

Majority of cases of H1N1 infections have been found in Western countries such as the US, Canada, UK and Australia, where genetically modified french fries are consumed the most. Moreover, the young adult population is worst hit by the swine flu; the same segment of population that loves to consume fries.

At least that’s what the report claims.

So, what do you think? Are you buying this?

It smells like a sack of rotten potatoes to me.

 

Image: flick

Post from: Genetics & Health

In view of the reaction to Atul Gawande’s recent New Yorker article I thought it would be interesting to explore some of the many reasons for practice variation. A popular perception is that it’s a lot about greed, and Gawande provided some extreme anecdotes which suggest, on first glance, that this is the case. Objective evidence, however, suggests otherwise. Here’s a run down.

Physicians with risk averse personality profiles order more tests.

Malpractice fear drives referrals to specialists.

Internists have higher utilization than FPs according to multiple studies, attributable to being more risk averse.

I have found no study looking at greed as a driver of utilization.

The horribly ill patients who are typically admitted to the hospital often have electrolyte disturbances or other conditions that may prolong the QT interval. This calls for special vigilance in drug therapy, as the list of QT prolonging drugs is daunting. This brief article from The Hospitalist has some pointers. You could just about make the case for doing an electrocardiogram on all hospitalized patients.

---has very poor sensitivity and only fair specificity. A new study shows that positive electrocardiographic findings indicative of right ventricular strain are additive to the prognostic information gained from echocardiography. The two techniques are complementary.

Unfortunately, accidents and tragedies often increase in the summertime. This year is no different, as Texas is already on track for a record year of drownings, which increased to 50...

As people with diabetes or parents of children with diabetes, we all know how difficult it is to manage the never-ending balance of food, insulin, exercise and myriad of other endlessly circumvolving variables.  Now imagine having to handle all of that turmoil for FOUR children. Meet Ellen and Dave Gould, parents of EIGHT children ages [...]

This topic seems to be enjoying a resurgence of attention in the literature, perhaps as a result of its importance in bed control and the role of telemetry over use in emergency department congestion. It’s clear that telemetry use far exceeds indications deemed appropriate in the guidelines. The latest review is here.

My previous post on this topic is here.

An American Heart Association Scientific Statement which updates the 1991 ACC guidelines is linked here.

There are several web based reproductions of heart sounds, most of which are of poor quality. This resource from the Texas Heart Institute is the best educational site for auscultation I’ve seen yet.