Medical News and ResearchMedical News and Research

KevinMD’s Take, June 17, 2013

Mon, 17 Jun 2013 06:30:55 +0000

By Kevin, M.D.

The technology to perform an EKG with your smartphone is here. Known as the AliveCor EKG, it has been endorsed by prominent doctors, like cardiologist Eric Topol.

Wes Fisher, another cardiologist, is more reserved and wonders about the legal implications of such a device.

"Until a clear interpretation workflow is established that can provide comprehensive coverage of interpretations paired with a well-defined and easy-to-use interface with a medical record system, patients should understand doctors’ possible hesitation to prescribing this device to a multitude of patients for personal use," he writes.

The utility of mobile apps is expanding before we can understand their malpractice ramifications. Unfortunately, that's the society we live in. Until we do, doctors' optimism about prescribing the apps should be measured.

***

Should physicians write?

As a blogger myself, I say "of course!"

Fellow physician-writer Louise Aronson agrees, and gives a more detailed response.

According to the Physician Charter, a fundamental responsibility of physicians is to provide "expert advice to society on matters of health.”

"What are the most effective ways to reach large numbers of people?" asks Dr. Aronson. "There are really just three modalities: text, audio, and video. And the latter two, to be effective, often have scripts. Moreover, they always require the clarity of language and expression, mastery of storytelling, and judicious use of data that can best be taught and practiced through writing."

Indeed, communicating beyond the exam room requires good writing skills. And with more patients researching health information online, it becomes more important for doctors to populate the Web with reputable content.

Doc Complains, Gets ‘Misleading’ Screening Ads Banned

Thu, 13 Jun 2013 15:49:26 +0000

By Gary Schwitzer

On a BMJ blog, Dr. Margaret McCartney writes about her irritation after seeing ads on the side of buses in Glasgow (where she lives) promoting screening tests but not divulging that this was to recruit people into clinical trials. She and her daughter took photos of the ads, and she shared those with me:

She complained to the UK agency that regulates advertising across all media. And that agency ruled that the ads were misleading and must not appear again in their current form. The agency gave this description of the ads:

Three posters on buses in Glasgow promoted a company recruiting for, and running, clinical trials: a. A bus poster, which displayed an image of an X-rayed hand with fingers crossed, was headlined “1 in 2 women over 50 will break a bone due to Osteoporosis”. Text stated “To find out about our FREE Bone Density scanning programme visit www.improvinghealth.com, call 0800 XXX XXXX or text ‘scan’ to 80XXX. Your local Synexus Centre is located in Glasgow. help us to help you. SYNEXUS”. b. A second bus poster, which displayed an image of a female using an inhaler, was headlined “Do you have asthma?”. Text stated “Register for a complimentary health check today and you could be part of our research into the future of asthma. Text asthma to 88XXX, call 0141 XXX XXXX or visit www.challenge-asthma.com. SYNEXUS. Help us to help you”. c. A third bus poster, which displayed an image of an older woman, was headlined “Concerned about diabetes?”. Text stated “To find out about our free health screening programme, visit www.challenge-heartdisease.com, call 0800 XXX XXXX or text ‘heart’ to 81XXX. Your local Synexus Centre is located in Glasgow. We’re getting to the heart of the matter. SYNEXUS”.

McCartney writes: “I wonder if advertising health tests direct to the public is ever going to be good for us.” Certainly not if only the potential benefits are emphasized, and the potential harms are ignored. This is not merely an advertising ethics issue; it’s a health care and medical research ethics issue as well.

‘Here They Go Again’ – Three New Proton Beam Facilities Within 40 Miles

Wed, 12 Jun 2013 15:55:01 +0000

By Gary Schwitzer

“When it comes to reining in health care spending, it still seems like each hospital administrator thinks the guy at the other hospital should do it.” That was the lead as Jenny Gold of Kaiser Health News reported that two Washington, D.C. hospitals – 3 miles apart – are building expensive proton beam radiation centers for cancer treatment. The two – Johns Hopkins’ Sibley Memorial Hospital and MedStar Health’s Georgetown University Hospital – will also compete with another new facility in downtown Baltimore – about 40 miles away. She explains:

“While the treatment has shown promise for treating brain and spinal tumors in children, the Hopkins facility is explicitly banned from treating pediatric cancers. That’s because Sibley Memorial Hospital doesn’t have a pediatric unit, nor does it have a permission from the city to build one. [The three centers] will all have to turn to treating adult cancers — largely prostate cancer, for which proton therapy hasn’t been proved to improve results for patients or to reduce side effects — to stay profitable. … “Neither [Hopkins nor MedStar] should be building,” says Dr. Ezekiel Emanuel, a former health care adviser to the Obama administration who is now at the University of Pennsylvania. “We don’t have evidence that there’s a need for them in terms of medical care. They’re simply done to generate profits.” The higher costs of proton services ultimately trickle down to taxpayers, employers and consumers in the form of higher health insurance premiums. “It’s hard to bend the cost curve when you’re spending a lot of money,” says Emanuel. “These are tens if not hundreds of thousands of dollars in treatment for interventions that do not improve survival, improve quality of life, decrease side effects or save money.” There are already 11 proton therapy centers in the U.S., and the Maryland Proton Treatment Center in Baltimore is one of 17 more on the way.

Former Boston medical center CEO Paul Levy wrote on Twitter, “Here they go again.” In a New York Times editorial last year, Ezekiel Emanuel and Steven Pearson referred to the proliferation of proton beam therapy facilities as “crazy medicine and unsustainable public policy.” If you missed it, Johns Hopkins Medicine also sent out a news release about its robotic surgery system. We’ve written many past posts about questions of “the medical arms race” concerning both robotic surgery and proton beam therapy.

Carl Hiaasen Takes on Medicare Fraud

Wed, 12 Jun 2013 10:30:17 +0000

By Todd Neale

The last thing I expected to get out of a Carl Hiaasen book signing was fodder for a blog post, but that's exactly what I walked away with (in addition to a couple of signed books) after leaving the Union Square Barnes & Noble on Tuesday night.

If you don't know who Hiaasen is, he's the author of novels for adults and kids that are centered around shady dealings of one sort or another down in Florida. He's also a long-time writer for the Miami Herald and a native-born Floridian. His books -- the adult ones, anyway; I haven't read the kids' tomes -- always have a bizarre cast of characters and plots that tend to devolve into the depths of weirdness.

So why am I telling you this? Because the crime at the center of Hiaasen's latest book, Bad Monkey, is Medicare fraud. The fraudster files bogus claims for motorized scooters and when federal authorities start to close in, he vanishes. Tourists later discover an arm floating in the waters of the Florida Keys, and it belongs to the fraudster. The book takes off from there.

As a columnist, Hiaasen often writes about the seedier side of the state he calls home, and the fact that Florida has the distinction of being the "Medicare fraud capital of the U.S." -- as he puts it -- inspired him to tackle the subject in a novel.

I was curious about whether Florida actually is ground zero for Medicare fraud, and it appears that the state has a strong case.

The government entities leading the way in fighting Medicare fraud are the Health Care Fraud Prevention and Enforcement Action Team (HEAT) -- a joint task force of the Department of Health and Human Services and Department of Justice -- and the Medicare Fraud Strike Force (MFSF), which operates as part of HEAT.

The MFSF focuses on nine U.S. cities, and you'll notice that Florida is the only state represented twice on the list, which includes Baton Rouge, La.; Brookyln, N.Y.; Chicago; Dallas; Detroit; Houston; Los Angeles; Miami-Dade; and Tampa Bay, Fla.

In its latest action, announced in an HHS press release last month, the MFSF charged 89 people -- including doctors, nurses, and other medical professionals -- with Medicare fraud involving about $223 million in false billing.

"The defendants charged are accused of various healthcare fraud-related crimes, including conspiracy to commit healthcare fraud, violations of the anti-kickback statutes, and money laundering," according to the release. "The charges are based on a variety of alleged fraud schemes involving various medical treatments and services, primarily home healthcare, but also mental health services, psychotherapy, physical and occupational therapy, durable medical equipment, and ambulance services."

The largest proportion of the defendants came from Florida, including 25 from Miami and nine from Tampa Bay. That trend is consistent with four other national anti-fraud operations covered by MedPage Today since 2010, with Miami contributing the greatest number of individuals charged in each case.

So Hiaasen seems to know what he's talking about when he singles out Florida as the worst offender for Medicare fraud. It'll be interesting to see what he does with the topic as the events in Bad Monkey spin out of control, which is inevitable.

KevinMD’s Take, June 12, 2013

Wed, 12 Jun 2013 08:22:03 +0000

By Kevin, M.D.

What really happens at a morbidity and mortality (M&M) conference?

Is it really as confrontational as some television shows, like the recently cancelled "Monday Mornings," suggest?

A surgeon-blogger writes about what goes on behind the scenes.

"Unlike the Monday Mornings version, M&M conference is not where attending surgeons are browbeaten, tricked or fired. Of course, the real conference is far less dramatic (most of the time)," he writes. "There can be raised voices and sometimes arguments occur, but the focus of the conference is usually more on education and quality improvement."

Being less confrontational is certainly a step in the right direction. These conferences should focus on root causes of errors, and a less adversarial approach would encourage doctors to be more forthcoming when discussing mistakes.

***

Is America really at war with its doctors?

It seems that way, writes an anesthesiologist in a provocative opinion piece.

"Winning the war would have meant doctors have fair pay, supportive work environments, professional autonomy, and minimal obstruction to the sacred practice of good medicine," she writes.

Doctors have lost all four battles. Regulation has decreased the autonomy of physicians and contributed to the epidemic of doctor burnout. With demand for medical services projected to increase going forward, physicians are needed more than ever. Devaluing their work strikes me as a poor strategy.

Heart Valve Battle Looks Bleak for CoreValve

Tue, 11 Jun 2013 10:07:13 +0000

By Chris Kaiser

Edwards Lifesciences and Medtronic have been battling each other for half a dozen years (at least) over a heart valve patent, and recent news suggests Germany's District Court of Mannheim will favor Edwards.

At the heart of the matter is Edwards' Andersen patent for its Sapien transcatheter heart valve, which is intended for patients with severe aortic stenosis.

CoreValve (which Medtronic bought in 2009) and Edwards have suits and countersuits against each other in several countries.

But back in 2008, the German Federal Court ruled that CoreValve did not infringe on the German Andersen patent.

In 2009-2010, a German district court and an appeals court re-affirmed there was no patent infringement by CoreValve.

But analysts have recently predicted that Edwards has "a 60% probability" of coming out the winner in this battle, according to fiercemedicaldevices.com.

The win for Edwards could also include a permanent ban on selling the CoreValve in Germany, the largest market in Europe for transcatheter aortic valve implantation (TAVI).

The two companies have come to blows in the U.S. as well.

In 2010, a U.S. federal jury found that Medtronic's CoreValve willfully infringed the U.S. Andersen patent.

Later, the District Court of Delaware upheld the 2010 decision against CoreValve and awarded Edwards $83 million in damages.

What is not clear, according to Tom Zuber and Jeff Zuber of the law firm Zuber Lawler & Del Duca, is whether the District Court of Delaware (which now has jurisdiction over the case), will impose a permanent injunction against CoreValve for future infringement, which Edwards has requested.

Both companies received CE Mark in 2007 to commercially sell their aortic valve systems in Europe.

The FDA approved the Sapien valve in 2011 and Medtronic's CoreValve is currently undergoing clinical trials in the U.S.

Low Blood Pressure May Weaken Brains of Some Heart Patients

Brain Diseases New Links: MedlinePlus RSS Feed — Mon, 10 Jun 2013 20:00:00 +0000

Pressure that's too low -- or too high -- might damage brain cells, new research suggests

MONDAY, June 10 (HealthDay News) -- People suffering from cardiovascular disease who have lower-than-normal blood pressure may face a higher risk of brain atrophy -- the death of brain cells or connections between brain cells, Dutch researchers report.

Such brain atrophy can lead to Alzheimer's disease or dementia in these patients. In contrast, similar patients with high blood pressure can slow brain atrophy by lowering their blood pressure, the researchers added.

Blood pressure is measured using two readings. The top number, called systolic pressure, gauges the pressure of blood moving through arteries. The bottom number, called diastolic pressure, measures the pressure in the arteries between heartbeats. Normal blood pressure for adults is less than 120/80, according to the U.S. National Heart, Lung, and Blood Institute.

For the study, 70 to 90 was considered normal diastolic blood pressure, while under 70 was considered low.

"Our data might suggest that patients with cardiovascular disease represent a subgroup within the general population in whom low diastolic blood pressure might be harmful," said researcher Dr. Majon Muller, an epidemiologist and geriatrician at VU University Medical Center in Amsterdam.

On the other hand, lowering blood pressure in people with high blood pressure might slow brain atrophy, she said.

"Our findings could imply that blood pressure lowering is beneficial in patients with higher blood pressure levels, but one should be cautious with further blood pressure lowering in patients who already have low diastolic blood pressure," Muller added.

The report was published in the June 10 online edition of JAMA Neurology.

A U.S. expert noted the complex effects of blood pressure levels on the brain.

"High blood pressure has been shown to increase the risk of vascular brain lesions and brain atrophy. Trials of blood pressure lowering in patients with hypertension have shown reduced risk of brain lesions," said Dr. Gregg Fonarow, a professor of cardiology at the University of California, Los Angeles, and a spokesman for the American Heart Association.

However, in patients with hypertension, the relationship between the levels of systolic and diastolic blood pressure and brain atrophy has been less clear, he said.

This new study suggests that low diastolic blood pressure levels were associated with brain atrophy regardless of blood pressure levels after patients developed dementia, Fonarow said.

"These findings suggest that while treatment and control of high blood pressure is very important for brain and cardiovascular health, caution is needed in patients who have low diastolic blood pressure levels," he said.

To see what changes blood pressure would make in the progression of brain atrophy, Muller's group studied 663 patients who suffered from heart disease, cardiovascular disease, peripheral artery disease or abdominal aortic aneurysm. The average age of participants was 57 and most were men.

People whose diastolic blood pressure was below 70 had more brain atrophy over time, the study found. For people with higher-than-normal blood pressure, brain atrophy decreased when their blood pressure did. When blood pressure rose, however, atrophy increased.

Another expert, Dr. Sam Gandy, associate director of the Mount Sinai Alzheimer's Disease Research Center in New York City, said that the finding "is an important cautionary tale."

"This implies that one must adapt the approach to the individual patient. Correction of hypertension is helpful, but reducing blood pressure in patients with normal blood pressure is risky and complicated," Gandy said.

Although the study found an association between low diastolic blood pressure and the risk of developing brain atrophy for people with artery disease, it did not establish a cause-and-effect relationship.

SOURCES: Majon Muller, M.D., Ph.D., epidemiologist and geriatrician, VU University Medical Center, Amsterdam; Sam Gandy, M.D., associate director, Mount Sinai Alzheimer's Disease Research Center, New York City; Gregg Fonarow, M.D, professor, cardiology, University of California, Los Angeles, and spokesman, American Heart Association; June 10, 2013, JAMA Neurology, online

Hooters, Surgery Tweeters, and Media Manipulators – A Medical Marketing Roundup

Mon, 10 Jun 2013 15:29:23 +0000

By Gary Schwitzer

Novartis and Hooters

Is it a kickback to get doctors to prescribe certain drugs? Or is it truly an educational meeting for doctors – that happens to be held at places like Hooters across the country? Read the Wall Street Journal’s story, “U.S. Accuses Novartis of Kickbacks” (subscription required). It’s about a civil fraud lawsuit “in which prosecutors alleged the company’s U.S. unit paid kickbacks and provided lavish dinners for doctors to encourage them to prescribe certain brand-name drugs to treat hypertension and other maladies.” The story reported: “Many programs took place with fewer than three health-care professionals in attendance, and sometimes only with members of the speaker’s own medical practice, according to the complaint.” John Mack had some fun with it on his Pharma Marketing blog.

Story by TheFix.com

Gallery of Live-Tweeted Surgeries

The Live Science site has been following the trend of live-streaming and live-tweeting of surgeries. Hermann Hospital in Houston has live-tweeted heart surgery, brain surgery and a c-section delivery – leading to this slide show series called, “Social Surgery: A Gallery of Live-Tweeted Operations.” From the Live Science site:

“Something going wrong is a primary concern for doctors, who, by all ethical standards, must put their patients first. The Society of Thoracic Surgeons goes so far as to frown upon live broadcasts of surgery even for the benefit of other physicians, unless the educational value is high. Twitter broadcasting is strongly condemned by the group. “Surgeons should not participate in live surgery broadcasts to the public or lay audiences using any medium, including television and the Internet,” according to the society’s guidelines. Some patients question the practice, too. Elaine Schattner, a journalist and physician who has undergone multiple major surgeries herself, questions putting hospital resources into live-tweeting. “The way I see it, most hospitals are short-staffed, so to have a person who is the designated tweeter paid for by the hospital is absurd,” Schattner told LiveScience. Schattner also expressed concern about potential distractions to the surgeon and whether social media surgeries serve a purpose beyond public relations and marketing for a practice or hospital. There’s no extra benefit to live surgery compared with watching prerecorded videos on YouTube or elsewhere, she said.”

Impact of Marketing and PR on the News Media

And let’s not lose sight of the threat of marketing’s impact on journalism. The Pew Research Center’s Project for Excellence in Journalism 2013 annual report on “The State of the News Media” reports:

“…a news industry that is more undermanned and unprepared to uncover stories, dig deep into emerging ones or to question information put into its hands. And findings from our new public opinion survey released in this report reveal that the public is taking notice. Nearly one-third of the respondents (31%) have deserted a news outlet because it no longer provides the news and information they had grown accustomed to. … And recently, journalist David Cay Johnston in writing about a pitch from one corporate marketer that included a “vacation reward” for running his stories, remarked, “Journalists get lots of pitches like this these days, which is partly a reflection of how the number of journalists has shriveled while the number of publicists has grown.” Indeed, an analysis of Census Bureau data by Robert McChesney and John Nichols found the ratio of public relations workers to journalists grew from 1.2 to 1 in 1980 to 3.6 to 1 in 2008—and the gap has likely only widened since.”

You can read some of our past blog posts about medical marketing practices. Or other blog posts on some health care public relations practices.

KevinMD’s Take, June 10, 2013

Mon, 10 Jun 2013 13:40:12 +0000

By Kevin, M.D.

Most doctors don't step into the shoes of their patients, or their patients' caregivers.

In this powerful story, physician Scott Finkelstein's wife was diagnosed with breast cancer.

Here's how the experience has changed him as a physician: "This experience showed me that while my body wasn’t sick, being a caregiver presented unexpected and often overlooked challenges. Caregivers may not need physical support, but they need just as much emotional support. Through this realization, I know that I have become a better doctor. I make sure that everyone who accompanies a patient or loved one to surgery has a chance to speak and ask questions. I listen more. I make eye contact and hold my patient’s hand. Although I was trained to maintain a professional distance from my patients, I am now more present than ever. And I know my patients appreciate this just as my wife did."

Most doctors don't have many of the conditions they treat. But for those that do, the bond that forms with their patients cannot be learned in a textbook, or practiced through residency. There is no substitute for experiencing a patient's, or caregiver's, point of view first hand.

***

Should the parents be allowed to witness CPR on their children in the hospital setting?

It's a controversial question, as a pediatric intensivist notes first-hand from the myriad of comments he received when he asked on his own blog.

He cites a study from the New England Journal of Medicine saying that families who were allowed to witness CPR had a reduction in psychological symptoms in the aftermath.

While the situation may be different for adult patients, for his pediatric population, parents almost always choose to stay when asked.

At the very least, give them the option.

Scorpions Can’t Hold Their Liquor

Fri, 07 Jun 2013 16:02:36 +0000

By Shalmali Pal

There was a scene in the the last James Bond film, Skyfall, where our superhero spy had to down a shot of tequila while balancing a nasty-looking scorpion on his arm. It reminded me that since I moved to Arizona 4 years ago, I've amassed a fair amount of advice on what to do if I run afoul of the desert's less friendly inhabitants. And by advice, I mean slightly wacky, folksy remedies that may not work, but still seem useful to know. Here are few of them.

What's Your Poison?

What if Mr. Bond had lost his battle with the scorpion? Dousing the stung body part in tequila may help, as the spirit's anti-toxic effects can lessen the pain, burning, and tingling that accompany a scorpion sting.

There's some science to back this claim: A Mexican study found that extracts from agave plants, from which tequila is distilled, reduced the growth of toxic compounds produced by fungi (Int J Food Microbiol 2005;98:271-279).

When I told my husband, who's lived in Tucson for 15 years, about this booze-based remedy, he was skeptical, but responded: "Just don't use the aged, good stuff!" Now a super-cheap bottle of tequila has a home on our bar.

The ED: Scarier than a Rattlesnake?

Arizona has more than 80 types of snakes, and about 20 of those are venomous. I steer clear of any and all snakes, but what I really want to avoid is a trip to the emergency department (ED) because the hospital bill may be worse than the bite.

Nearly every year, there's a news story about a post-rattlesnake attack victim getting treated in the ED and subsequently receiving a hospital invoice ranging from $43,000 to $145,000. In one instance, two doses of the anti-venom Crotalidae Polyvalent Immune Fab cost nearly $130,000.

So I take a more preventive and less pricey approach: I always wear shoes outside; look down and around on the ground before moving forward; and if I do spy something that even remotely resembles a snake, I slither away faster than it can.

When Cacti Attack!

It seems like it would be easy to avoid getting caught in a cactus: Do not touch. But it's not that simple, because even the lightest, accidental brush can unleash havoc. The Sonoran desert cacti -- such as the paddle cactus (below left) -- don't just launch a single needle or two; they'll send multiple stickers out, some of which are extremely thin and will embed themselves deep in the skin.

There is one cactus called a jumping cholla (pronounced choy-a -- below right) with hollow needles that detach easily from the main plant and seem to leap out at the poor creature who is too close for comfort.

Needle removal options include slapping duct tape on the affected area, rubbing vigorously, and ripping off quickly (bonus: hair removal) or raking the area several times with a fine-tooth plastic comb.

A friend told me about a "black goop" that ranchers use to remove cactus needles from horses, so I hightailed it to a feed store and actually asked for some black goop. The salesman politely handed me a jar although the look on his face said "City slickers! They don't know their ichthammol drawing salve from their elbows!"

The basic ingredient in this salve is ammonium bituminosulfonate and it draws the needles to the skin's surface for easier removal. However, the salve has to stay on for a couple of days, and it smells terrible.

Soothe the Savage Beast

Javelinas are a common sight in Tucson; they often hang out in my front yard. Members of the peccary family, these herbivores have sharp teeth, a coarse coat of hair, and can weigh in at 60 lbs. They are a shy bunch but if they feel cornered, they'll attack.

One defensive maneuver is to sing to the javelinas, which will calm them, and then slowly back away. I've been told they prefer higher-pitched female voices, so men may have to use their best Prince-style falsettos.

Fortunately, I'm not expected to sing well or even on-key; the javelinas aren't going to go all Simon Cowell on me.

Smells like Teen Truck Fumes

Tucson's population is around 600,000, but during the summer, there's a dramatic drop when the snowbirds -- retirees from other parts of the U.S. who live here during the cooler months -- go home. As a result, there's an increase in what I consider a serious threat to my safety -- a bored teenager racing around in an oversized pick-up truck. Between the relatively empty roadways and the town's high speed limits (45 mph), it's not uncommon to see these youngsters zooming through traffic, taking harrowing turns, and gunning through intersections.

When I come upon these accelerating adolescents, I move to the outside lane, maintain the speed limit so they'll pass me quickly, and hope their natural enemy is lying in wait: A sheriff's deputy with a radar detector.