Patient care

HbA1c Can Diagnose Diabetes

July 13th, 2009 | No Comments | Source: USA Today

The glycated hemoglobin, or HbA1c blood test has been approved as a legit means to diagnose diabetes.

expertpanelistmembersAn international committee of experts made the announcement at the recently concluded meeting of the American Diabetes Association.

The test is fit for use, it concluded, in people of all ages but not for pregnant women.

“This is a major departure from the way diabetes has been diagnosed in the past,” David Nathan told USAToday.

Nathan, the director of the Diabetes Center at Massachusetts General Hospital, chaired the august body which included investigators from the ADA, the International Diabetes Federation (IDF), and the European Association for the Study of Diabetes (EASD).

The committee based its conclusion on a review of scientific literature on the matter.

Prior to the announcement, diabetes had been diagnosed using either a fasting blood glucose or an oral glucose tolerance test. Both tests are sensitive but prone to false positive results caused by eating prior to the test and intercurrent illnesses.

In contrast, the HbA1c test assesses glucose levels over the 2-3 months prior to the stick. It is not nearly as likely to produce a false positive result, does not require that one fast prior to the test, and can be done at any time of the day.

The thing that had been preventing the test from being used as a diagnostic tool before the announcement was that influential diabetes groups had not agreed on the result that constitutes a positive diagnosis.

Nathan’s group more or less settled the matter, saying that anyone with a level of 6.5% or higher had diabetes.

The ADA itself has yet to sign off of these recommendations, however. It’ll begin its own investigation in the near future.

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Bleach Quells Eczema

June 2nd, 2009 | 1 Comment | Source: BurrillReport, Pediatrics

eczemazapperNearly one in 5 school-age children are afflicted with eczema, a monumentally annoying skin disorder characterized by red, itchy, patchy lesions that when scratched, mature into crusty, weeping sores which often become superinfected with staphylococcus aureus.

Once bacterial superinfection occurs, physicians typically prescribe oral or topical antibiotics with the downside being rapid development of resistance including that dreaded scourge, MRSA.

But now scientists at Northwestern are reporting that adding a small amount of household bleach to the bathwater of children with moderate to severe eczema markedly improves the condition.

Jennifer Huang, Amy Paller and colleagues prescribed oral antibiotics to 31 patients who were between the ages of 6 months and 17 years and were afflicted by eczema that had been complicated by staphylococcal superinfection.

Half the patients were also instructed to bathe in a standard tub into which a half a cup of bleach had been added. These patients also received intranasal antibiotic ointment to eliminate bacterial colonization of that orifice.

keepthesesocksawayfrombleachControls added an inert substance that looked and smelled like bleach to their baths, and applied an ointment containing fake antibiotics into their noses.

All subjects were instructed to bathe twice a week for 5-10 minutes.

The scientists saw so much improvement in the treatment group, they halted the study early and switched kids in the control group over to the bleach.

“The eczema kept getting better and better with the bleach baths, and these baths prevented it from flaring again,” Paller told BurrillReport

“We presume the bleach has antibacterial properties and decreased the number of bacteria on the skin, which is one of the drivers of flares,” added the Chariman of Pediatric Dermatology.
 
The write-up is in Pediatrics.

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Time for the Big Easy

March 20th, 2009 | No Comments | Source: Archives Int. Medicine, MedPageToday

thisgoeswhere?That Canadian study showing colonoscopy screening wasn’t as effective as first thought caused quite a dust up around the New Year, but consensus remains strong that the Big Easy is a life-saver and people need to get it done.

Yet only 60% of eligible patients report being up-to-date with the test and harried physicians often don’t have the time to discuss preventive services with their patients.

Which is why the results of a trial of a decidedly low-tech reminder system are so heartening.

timeforthebigeasyThomas Sequist and colleagues from the Brigham implemented a randomized trial of mailed reminders to patients and lo and behold, they actually improved colonoscopy utilization!

The scientists enrolled 21,860 patients between the ages 50-80 from 11 clinics during 2006-2007. All patients were overdue for the ‘scope.

Subjects either received nothing or a mailing that contained an educational pamphlet, a fecal occult blood testing pad, and instructions for scheduling a colonoscopy.

The scientists also sent electronic reminders to the patients’ primary care physicians.

Among patients who received the mailed reminders, 44% got it done. The number was 38% in the control group.

Reminders were increasingly effective as subjects got older, with the difference favoring the reminded group rising from 3.7% for ages 50 to 59 to 10.1% for ages 70 to 80.

The study is in the Archives of Internal Medicine.

if1worksdoes20workbetter?“Our findings underscore that informed patients can play an active role in completing effective preventive services,” the scientists concluded.

Interestingly, the electronic reminders to physicians didn’t boost colonoscopy rates, “in part because over one-third of patients had no visits with their primary care physician during the 15-month study period,” the scientists reported.

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Delaying Breast Cancer Treatment

December 17th, 2008 | 1 Comment | Source: Cancer, NY Times

Nearly 20% of breast cancer patients either delayed radiation therapy or did not finish a full course of therapy following breast-conserving surgery, and they experienced worse outcomes as a result, according to a study in Cancer.

Scientists at Weil Cornell Medical College studied 7,791 patients who were at least 66 years old and had been diagnosed with Stage 1 breast cancer between 1991 and 1999.

They found that 16% experienced a delay in the onset of radiation therapy of at least 8 weeks following surgery, and 3% did not complete a full course of therapy, defined as less than 3 weeks instead of the usual course of 5-7 weeks.

 African-Americans were 50% more likely to delay treatment, and women living in high poverty areas were less likely to complete their treatments.

Women who delayed radiation therapy for at least 8 weeks were 40% more likely to experience a recurrence of breast cancer. Those who waited more than 12 weeks were 4 times more likely to experience a recurrence.

Patients who did not complete their radiation therapy had a 32% higher mortality.

“One of the big problems is that care has to be coordinated to avoid these kinds of delays and lack of completion, especially for patients from a lower socioeconomic status,” study leader Heather Taffet Gold told the New York Times.

That’s easier said than done.

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US Doctors Often Prescribe Placebos

October 27th, 2008 | No Comments | Source: British Medical Journal

About half the US physicians polled in a recent survey regularly prescribe placebos and most believe the practice is ethical, according to a report in the British Medical Journal.

The placebo effect refers to perceived clinical improvement caused by an inert substance such as a sugar pill or salt water, or one that has no impact on the condition for which it is prescribed. Since the 1960s, many clinicians and ethicists have frowned on placebo therapy because it involves deception and thus disregards principles of informed consent and patient autonomy.  Others disagree, noting that placebos can be the most effective treatment for certain conditions, and they can be administered without deception.

In the BMJ study, scientists surveyed 600 internists and 600 rheumatologists they had randomly selected from the American Medical Association master files. 46-58% (depending upon how the question was worded) reported using placebos regularly. The most common placebos were over-the-counter analgesics (41%) and vitamins (38%). Thirteen percent used antibiotics and sedatives as placebos.

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Kids and Statins

September 25th, 2008 | Comments Off on Kids and Statins | Source: NEJM

In July, the American Academy of Pediatrics (AAP) updated its guidelines for managing high cholesterol in children. The revisions generated a blizzard of media attention that surprised many in the pediatrics community.

After all, the revisions were for the most part incremental compared with previous iterations: slightly more comprehensive screening, an emphasis on the quality of fat intake rather than total fat intake, and a reduction in the recommended age for initiating drug therapy from 10 to 8 years.

There was one thing though, that was not incremental. The AAP now recommends statins as potential first-line cholesterol-lowering drugs for kids in whom efforts to lose weight and exercise fail to sufficiently reduce high cholesterol level. The older version made no mention of statins and recommended bile acid-binding drugs instead.

The bile acid binders don’t work well and are poorly tolerated. Statins work exceedingly well and are well tolerated in adults. The problem is that there is only limited, short-term data showing statins are safe in kids. In selecting a drug to recommend, the AAP had to trade-off unknown long-term risks of statins vs. their clear superiority as cholesterol lowering agents.

Sales of statins are already in the billions and how exactly can we subject our kids to unknown risks like that? The reasons for the firestorm are clear.

Now, two Harvard clinicians have posited that the epidemic of childhood obesity is the larger contextual issue at work here. That is what drives unprecedented numbers of kids to the point where they need cholesterol-lowering drugs in the first place. And that is what forces pediatricians to use other powerful “adult” drugs like diuretics and beta blockers for high blood pressure, insulin sensitizers for metabolic syndrome, and even aspirin for coagulopathies that these kids end up with in addition to high cholesterol. We don’t know much about how these drugs work in kids, either.

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ER Patients Left Clueless

September 19th, 2008 | No Comments | Source: NY Times

A study published in the Annals of Emergency Medicine found that the majority of patients who are discharged from emergency rooms leave with little understanding of what happened to them in the ER and what they are supposed to do to take care of themselves after returning home.

Investigators tracked 140 patients discharged from the ERs of two Michigan hospitals to determine whether they understood their diagnosis, treatment, home-care instructions and a list of signs which signified the need for immediate follow-up.

78% of the patients did not understand of at least one of these four areas, and half didn’t understand at least two of them.

The biggest problem was home-care instructions, things like when and how to take medications, activity limitations, wound care and the need for follow-up.

The communication breakdown often caused medication errors and complications necessitating return trips to the ER and even hospital admission.

ERs are a set-up for poor doctor-patient communication. Physicians are busy with multiple patients including some who are quite ill, and patients are distressed by the condition prompting their visit.

Experts suggest two strategies to reduce these errors. The first is a teach-back method in which a patient, ideally while accompanied by a friend or relative, repeats instructions to the physician. The second is a dual-discharge method in which a nurse follows up with patients after physicians discharge them.

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Colon Cancer Care: Not Good Enough

September 12th, 2008 | No Comments | Source: Reuters, WebMD

Proper treatment for colorectal cancer includes excising the tumor, surrounding tissue and nearby lymph nodes, and then checking the nodes for metastatic spread. Oncologists decide whether to give adjuvant therapy based on the lymph node analysis. If the tumor has spread but the lymph node analysis fails to pick this up, then the patient does not receive appropriately aggressive adjuvant therapy.

Twelve years ago, oncologists established a guideline to measure the quality of colorectal cancer care. The guideline calls for pathologists to examine at least 12 lymph nodes for metastatic spread in 75% of all tissue blocks received from presumed colorectal cancer surgeries. Back then, only 15% of hospitals met the guideline.

Now we have new data. The results are better, but far from adequate. Only 38% of hospitals meet the guideline, according to data soon to be released in the Journal of the National Cancer Institute. Community hospitals meet the guideline only 34% of the time, whereas comprehensive cancer centers meet it 78% of the time.

Why the poor results? Perhaps doctors don’t know they should check so many nodes. Perhaps they don’t understand the importance of lymph node analysis in determining adjuvant therapy. Perhaps surgeons don’t provide enough nodes to the pathologists, or pathologists don’t have time to analyze that many nodes. Maybe tissue preparation and storage techniques are inadequate.

Providers that are serious about improving care will embrace the new findings and start exploring these hypotheses one by one.

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