June 11, 2009

Metoclopramide for Hyperemesis Gravidarum

Hyperemesis gravidarum is a fancy way of saying really really bad "morning sickness," severe nausea and vomiting associated with pregnancy.

There have not a lot of drug options here in the U.S., ever since thalidomide was shown to cause severe birth defects - phocomelia, where the children have shortened "flipper" like limbs. As you might imagine, pregnant women are very hesitant to participate in drug trials. It is just as hard to get children enrolled in studies. Unfortunately, the fundamental goal of trying to protect infants and children gets warped from lack of knowledge... and we know very little about how to medicate lil kiddos!

NYT Health says that Metoclopramide is safe for pregnancy. Reglan, as it is more commonly known, is a common anti-nausea medication has been shown to be safe in over 80,000 births in southern Israel.
Our study [The Safety of Metoclopramide Use in the First Trimester of Pregnancy] is about 10 times larger than all of the other studies of this drug put together,” said Dr. Rafael Gorodischer, one of the study’s authors and a professor emeritus of pediatrics at Ben-Gurion University in Israel. “We studied exposure in the first trimester because that is the most critical period for the development of the fetus, when most malformations would be caused by an external cause.”

“We can now say with a high degree of confidence that it’s a safe medication,” he said.

On the heels of this announcement, the British Medical Journal published their ClinicalEvidence on Nausea and Vomiting in Early Pregnancy (updated June 3rd 2009.)
Metoclopramide for treating hyperemesis gravidarum: One RCT found that metoclopramide was less effective at reducing vomiting episodes and readmission to the intensive care unit compared with corticosteroids. Other drugs and interventions may be more useful. Categorised as Unlikely to be beneficial.
Hm... so what does this mean? There is proven safety, but no clinical efficacy in severe cases. Clinical trials will need to be performed to look at this further. And thanks to this new study, we can! :)

June 09, 2009

Culture of Medicine II

The saga continues.

President Obama made some comments in the news regarding McAllen, Texas, suggesting that he read Dr. Atul Gawande's article on "the Cost Conundrum." Indeed, a recent New York Times article "Health Care Disparities Stirs a Fight" confirms this:
The [Gawande] article became required reading in the White House, with Mr. Obama even citing it at a meeting last week with two dozen Democratic senators.

“He came into the meeting with that article having affected his thinking dramatically,” said Senator Ron Wyden, Democrat of Oregon. “He, in effect, took that article and put it in front of a big group of senators and said, ‘This is what we’ve got to fix.’ ”
There's a fundamental difference in approaches between politicians and doctors. Docs are taught to care for every patient as if they were a member of our own family. Perhaps healthcare spending reflects this attitude. Politicians often abuse their constituents as if they are unwanted members of family. Perhaps they are willing to sacrifice X number of lives to save Y number of dollars in an annual budget. I say this only half-jokingly; it is a political necessity to be separated from the issues since there will always be a passionate dissenting group that protests any sort of stand they make. The difficulty, in politics as well as medicine, lies in controlling our emotions so they do not rule our intellect.

But how do you resolve the most personal and emotional issue of all?
I agree with Obama's eloquent response to the question: "Is healthcare a privilege, right or responsibility?":
I think it should be a right for every American. … for my mother to die of cancer at the age of 53 and have to spend the last months of her life in the hospital room arguing with insurance companies because they’re saying that this may be a pre-existing condition and they don’t have to pay her treatment, there’s something fundamentally wrong about that.

What price do you put on the health and welfare of your family? The New York article mentions data that provides EXACTLY what sort of numbers the government has been willing to spend on each person in 2006:
Nationally, according to the Dartmouth Atlas of Health Care, Medicare spent an average of $8,304 per beneficiary in 2006. Among states, New York was tops, at $9,564, and Hawaii was lowest, at $5,311.

Researchers at Dartmouth Medical School have also found wide variations within states and among cities. Medicare spent $16,351 per beneficiary in Miami in 2006, almost twice the average of $8,331 in San Francisco, they said.
Wow! Hawaii? I wonder if the fact that we also have mandatory healthcare (Pre-Paid Health Care Act of 1974) for full-time workers (>20 hours per week) in the nation has anything to do with these statistics. Massachussetts has a cool system too. Unfortunately, I don't know how well it is working out for them with the confluence of crises.

While it might sound appealing to adapt practices Aloha-style... that really would be doing things just for the love of it. A lot of doctors in Hawaii (regardless if they were Hawaiian doctors or not) are retiring, leaving the state or cutting back on their practice because of low reimbursements for Medicaid/QUEST and Medicare patients. So on the surface, it sounds appealing from a political point of view to slash wasteful spending but this can run antithetical to the goal of improving primary care by chasing doctors away.

Another thing that clogs up the gears of the glimmer of hope for Hawaii's healthcare... recently, the Medicaid/QUEST contract has gone out by two Mainland firms: UnitedHealth Group Inc. and WellCare Health Plans Inc. These companies were under investigation in billing fraud and improper claims scandals. Also, there is concern that the 37,000 enrolled aged, blind and disabled patients may have to change providers and lose continuity of care. Waianae and Waimanalo, the two regions on Oahu with the most Native-Hawaiians ironically are the two areas where the Community Health centers have opted out. (citation DENIED, see below)

I hope that the nation does not look at Hawaii for all the answers. It's much more likely that our docs have just gone uncompensated for a lot longer.

(Disclaimer: My commentary comes from the point of view of a medical student trying to stay informed on health-related news while studying to become a doctor in these changing times. As such, notmysecondopinions are not the best source around on health policy! I wish I could provide better local references... unfortunately the archives for the Honolulu Advertiser are on a pay-per-article access of $2-3! That model is detrimental to quick online Google News Searches for proper content.... gr.)

June 08, 2009

When Physics meets Physician.

With our powers combined...
I am Captain GEEKITUDE!

the image properties for this comic reveals the answer:
413 nanohertz, by the way.

June 07, 2009

Culture of Medicine

“So, what brings you in today?”

The young Filipino lady before me wrung her thin hands together. Her eyes betrayed a sense of fatigue as the corners of her eyes crinkled with anxiety. “Doctor, I am still feeling dizzy.”

Dizziness is a common complaint, but a difficult one to get a handle on. So many different things manifest themselves as dizziness… an unsteadiness with walking, the presyncopal feeling like you are going to pass out or just the sensation of violent spinning (the same as how you felt as a child after twirling in circles in the park or on an office chair). “What do you mean?”

“Well, it started almost two months ago. I had two episodes of dizziness that went on throughout the day that lasted for a few seconds. It felt like I was spinning in a circle. I was worried so I went online to see what could cause it. And I tried to make an appointment with my family physician but that would be in a few weeks so I saw an audiologist, a neurologist and a psychiatrist too. The audiologist tested me for nystagmus and had me perform the Dix-Hallpike maneuvers and asked me if I was dizzy. I told her no, but she noted some eye movements with the electronystagmogram so she diagnosed me with bilateral benign paroxysmal positional vertigo anyway. She prescribed some modified Epley maneuvers. The neurologist thought I might have migraine-related vertigo and put me on Amitryptyline. And this whole time I was doing research online I would read about these different symptoms and I would start to get them! My parents were very worried and suggested that I see a psychiatrist for my anxiety. He put me on Sertraline and Clonazepam.

Wow… I thought to myself. That’s quite a few specialists! This was a highly educated woman… she understood what nystagmus and Epley maneuvers were, and she could pronounce BPPV which put her pretty much at my level as far as I was concerned. Yet after seeing all of these different doctors, she was still here in the FM clinic even though her last visit was *flips through the chart* two weeks ago… when she was given meclizine for nausea.

“Uhm, I’m sorry…” I apologized. “I don’t understand. You’ve been diagnosed with BPPV and anxiety with the possibility of migraine-related vertigo… what can I do for you today?”

“I just want help. I am not feeling the spinning dizziness anymore. That was a long time ago. Now it is more of a… it’s hard to describe. It’s a rocking sensation.” “Like you’re on a boat?” I offered. “Sort of.”

It took me a while to piece the whole story together, but it seemed like her main complaint of dizziness had resolved but she was having residual anxiety and a number of other unusual symptoms -- getting visually overwhelmed by venetian blinds and patterns on carpets and being unable to go into a store without feeling anxious. However, she persisted on calling it dizziness with her subsequent physicians, although perhaps “uneasiness” would be a better way to put it. She told me that when she saw the audiologist and the neurologist, she was feeling very anxious about what was going on… but aside from performing tests like an ENG and an MRI of her head, they offered little comfort or support except to say “Go see your family physician.” She saw the psychiatrist about a week ago and after some persistent questioning about functioning, she said that she felt much better with the SSRI and benzodiazepine.

While I do not doubt the technical ability of the audiologist to interpret an ENG or a neurologist’s ability to identify and treat a migraine headache, these skills have their time and place. Her underlying problem was the anxiety she was having about the dizziness which took over and became a general sense of worry and unease. These specialists were ill-equipped to deal with that aspect -- and it was not until the Family Medicine doctor intervened that the whole picture could be assembled for the patient.

“You’ve seen a number of specialists and they have helped us rule out dangerous things like a brain tumor. You are still able to work and you have not had any difficulty walking, so functionally you’re doing really well. I understand that you’re feeling dizzy. The good news is that it is nothing serious as far as we can tell so far!” She left feeling reassured and I saw her with the psychiatrist as well to keep up the continuity of care.

The culture of medicine has changed and I feel that this is the crux of it! This patient had fallen through the cracks of the system. She tried to get an appointment with her PCP and when she couldn’t see her immediately, she resorted to a series of more expensive but ultimately unfulfilling specialists before her family helped her find someone address the underlying problem. She needed someone to put the pieces of the puzzle together. All too often, patients think that specialists are better than primary care for everything and this fragmentation of care leaves the patients with the pieces. Even worse, they assume that their primary care physician is automatically receiving all of these specialist reports! It is hard to piece all of these things together from a confused patient. I think that family medicine physicians are more than care coordinators or a bouncer at the specialty doorway. Similarly, specialists are more than just procedural technicians who punt back even small things like reassurance and education back to a family physician. All doctors go to medical school instead of OR or ER or psych ward school for a reason. We all know the basics of patient care.

A recent New Yorker article by Atul Gawande, entitled the “Cost Conundrum” also addresses this “Culture of Medicine.” Gawande outlines the problem of controlling health care costs by comparing the habits of physicians living in McAllen, Texas to nearby El Paso, Texas. He also went to Mayo clinic in Rochester, Minnesota, where he expected that their world-wide renown, high-tech and high quality of care would equate to more money.
McAllen’s Medicare expenditures per enrollee in 2006 were $15,000.
El Paso’s were $7,500.
Mayo clinic's were $6,688, less than either McAllen or El Paso!
What accounted for this difference?

McAllen physicians were highly enterprising and saw more patients each day, ordered more tests, and performed more aggressive interventions earlier. This padded their pockets a little bit more and thus rewarded, they continued onwards. This cycle of greed and profit is perfectly legitimate in our system of Relative Value Units (RVUs) where procedures are valued above cognition and doctors are compensated not be the quality of their patients’ health or their ability to make a diagnosis in a cost-effective manner… they are paid based on how many patients they see each day. This drives them to maximize their patient numbers and minimize their time with each of them! It becomes much easier to check a box and order an MRI of the brain than it is to spend an extra TEN minutes with a patient to sort out the true history and duration of dizziness -- but which one is more ideal?

I think that healthcare will be the next bubble to burst, now that dot.coms, real-estate markets, Wall Street and Auto makers collapsed under similarly empty value-for-cost pressures. Our healthcare dollars are being poured down a hole with little regard about whether they are spent on the RIGHT things. Gawande made a comment that I found Twitter-worthy:
“the most expensive equipment is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.”
The culture of medicine needs to change if we are going to fix our “broken system." Doctors cannot sit idly by and complain that it is insurance reimbursement or Medicare that is causing the problem. We need to admit that we are a part of the problem -- and seeing patients as a revenue stream and maximizing “business” by turning up the speed on the conveyor belt is not the solution! There is a sense of entitlement that because we have worked so hard and studied for so long to get to the position that we are in today (or in my case, soon will be,) we deserve the highest compensation for our services as possible. We measure our success based on how our income and lifestyle compares to our peers -- and so, in medical school, ironically fields like anesthesiology and radiology are highly valued despite the minimal patient contact. (It's a a pissing contest, if you pardon my French.) Our value to society and our true measure of success should be based on how healthy we keep our patients and how comfortable we make them feel when we cannot. That's our value to keep healthcare costs down!

We do not gain the sympathy of the general public by complaining -- “I don’t get paid enough to see patients!” Many patients who go to the doctors only to find a nurse practitioner or a physician assistant may just reply -- “You never saw me anyway.” We need to ground ourselves again and remember that our duty is to Care for patients before ourselves. That’s my interpretation of the words “Primary Care.” And that’s Not My Second Opinion!

June 04, 2009

Fitness Fun Facts

I was born in 1983 and will be 26 years old very soon! I weigh 145 lb. I am 5'7".

This information is very basic and very static (except for the ten pound weight gain since I started med school.) It is a part of who I am -- it's on my driver's license after all. It is a part of the Vital Signs, measurements that doctors utilize to determine your health!

Using myself as an example, I will go through a few calculations quickly that you might find interesting.

Body Mass Index (BMI):
Everyone and his mother knows what BMI is. It basically categorizes people as ok (BMI 18.5-25), overweight (>25), underweight(<18.5), obese (>30) or morbidly obese (>35).
You calculate it by taking your weight(in kg) and divide your height(in m) to the second power. Or use can use an online calculator or chart. Be warned though, that it just measures weight - it makes no distinction between fat and muscle (a confounding factor that tells us Arnold Schwartznegger is obese.)

Example: I am 5'7"->170cm->1.7m and 145lb -> 65.8kg.
Wt(kg) / Ht(m)^2 = BMI
65.8kg/1.70^2 = 22.77
My BMI is in between 18.5-25, so I am of normal weight for my height.

Ideal body weight (IBW):
This is something that differs for men and women.
in men, the IBW is 106 lb, plus 6 lb for every inch above 5'.
in women, the IBW is 100lb, plus 5 bl for every inch above 5'. Tough break!
Example: I am 5'7", therefore 7" above 5'.
106(lb) + 6(lb)*(7) = 148 lb
I notice that this does not correlate with other results I've found online... but this is the most straight-forward formula I've found (in an NMS Family Medicine text)

Measuring the pulse at the neck and wrist.Image via Wikipedia

Heart Rate target with exercise
Now for some of the fun stuff!
Your maximum heart rate is 220-age in beats/second. For moderate exercise, it should be 70% of that, or 0.7(220-age.)
Example: my age is 26.
0.7(220-26) = 135.8
You can find your pulse on your wrist (radial pulse) by making a fist and curling your hand to find the pit formed by your flexor tendons. Place your index and middle finger in that pit at the base of your thumb after relaxing your hand. To find your pulse in your neck (carotid pulse), poke the back corner of your jaw and slip your two fingers underneath the mandibular angle up against your neck. (The guy in the wikipedia picture has his fingers slightly malaligned for a perfect pulse... if he slid them down further he'd get it right on the pads of his fingers..) Count the beats for a minute (or alternatively, for 15 seconds and multiply by 4.)

Caloric expenditure for walking one mile:
How many calories (technically it is kilocal) do you burn walking one mile?
Take two thirds of your weight(in lb)! Simple... but scary too.
Example: I weigh 145#.
2/3(145) = 96.67 kcal
That means if I eat one of those little 100cal snack packs, I need to walk a mile to burn it off! If I drink an extra can of coke, I need to walk a mile and a half! No wonder I've gained weight. It also can be put into the context of cutting out one cookie every day. Over the course of a year, you would prevent an average of a ten pound weight gain assuming everything else was equal. (per personal communication with a physician who co-authored the DASH diet.)

Energy requirements for a typical day:
The kilocalories we need is about 10*IBW per day.
Example: my IBW(see above is 148).
10*148 = 1480
Assuming the average American male is ~5'9"...
10* (106+6*9) = 1600
That must be where the generic 1600 kcal ADA diet recommendation comes from.

Weight loss:
Mathematically, this requires a caloric deficit. That means more calories out (burned) than calories in (eaten.) There's a lot of different diet plans floating out there online on how to lose weight. I'm not going to go into that in this post. A very aggressive weight loss plan to lose a pound per week would be a 3500 cal/wk or 500 cal/day deficit.

That's walking five miles a day! A word of caution though... the goal is to lose fat, not water and muscle! Any faster and you risk dehydration, lactic acidosis buildup and muscle breakdown from starvation.

A more reasonable goal is perhaps simply walking a mile or two three to five days out of the week. A pound of weight loss every month may be seen with this. Coupled with diet changes... you'd be set to start living healthier and wiser! I know I'll try to keep these things in mind for myself as I strive to rebuild some of my lost muscle in lieu of brain power over the past three years of med school. ;)

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