What Has Happened to the Practice of Medicine?

I am constantly surprised and dismayed by the callousness and outright cruelty that has developed in the practice of medicine as the COVID-19 pandemic winds down. I am well aware of the weariness and exhaustion, physical and mental wellbeing, experienced by hospital-based physicians, emergency department physicians and nurses. I am so deeply indebted to them for their caring and concern. These health care professionals and their non-medical support staff have been dealing with severe staffing shortages in addition to a very ill patient population for over three years.  It’s everyone else I don’t understand.

Last week a spry and active 89-year-old widower called me in the evening to say that his lower abdominal wall hernia he has been ignoring despite advice to fix it, was stuck and causing severe pain. He had no fever, nausea or emesis – just pain and cramps. The only available care at that hour was in the hospital emergency department. I advised him to travel an extra 10 minutes to the facility his colon and rectal surgeon had privileges at. He chose to stay closer to home and went to the satellite facility of another hospital. He was seen in the ER, the hernia was pushed back into his belly (reduced is the medical term) and it was suggested he be admitted and surgically treated. He declined because he wanted his surgeon to perform the procedure.

At home he noticed that if he stayed on his back he felt fine. If he sat up or stood up the hernia popped out again and got stuck in place. The pain became severe, so he drove himself to the ER that his surgeon worked at. There they reduced the hernia again and for unclear reasons sent him home. They called his surgeon from the ER and he agreed to see him in his office in 48 hours. The next night he was back in the ER in pain and once again they pushed the hernia forcibly back in place and sent him home.

Yesterday the surgeon took him to the operating room, repaired the hernia using minimally invasive techniques, sent him to the recovery area and, when the patient demonstrated he could void without problems, discharged him home.  This is an 89-year-old man who lives alone. Yes he is fit and spry but he is 89 years old and going home with a wound left open with the surgeon instructing him to return to his office in 72 hours. The patient called a Home Health Agency and hired an aide to spend the night with him.

He called me from home that evening to ask me what he should take for pain Tylenol or Percocet. I was astounded and furious that a health care system would discharge an 89-year-old home four hours after they repaired an abdominal wall hernia.  I am all for cost containment and outpatient care where appropriate, but really? How do you send an 89-year-old home alone four hours after anesthesia and a hernia repair?  Where has the compassion and caring gone?

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New Oral Medication to Lower Cholesterol

Bempedoic Acid is a medication designed to be administered to patients who cannot tolerate statin drugs. It was studied in the CLEAR study whose results were presented this week at the meeting of American College of Cardiology.

The new medication is taken orally then undergoes metabolism in the liver from an inactive prodrug to an active medication. The drug does not interact with muscles, thus eliminating the muscle aches and pains seen with the statin drugs. The medicine did reduce LDL cholesterol modestly with only a 1.6% risk reduction in nonfatal outcomes over the four years of the study. This was a disappointing finding.

Bempedoic Acid is more costly than existing statins but less expensive than the injectable PCSK9 inhibitors Repatha or Praluent. Major adverse effects were a potential elevation of uric acid with more gout attacks, elevation of liver enzymes, gallstone formation and renal issues. The number of adverse effects when compared to placebo were quite small.  Despite being safe, its major drawback is that while it improved the lipid numbers slightly it did not seem to prolong life or reduce death when the results of the four-year study were projected out further over time.

As a clinician, it is wonderful to have a new relatively safe medication to help lower cholesterol.  Like most new medications, I prefer to hold off prescribing it until it has been used in the US market for six months to a year – especially since we have so many other proven medications to lower your cholesterol.

Diet Can Impact Development of Dementia

Health and scientific personnel have long stressed that we are what we eat. Diets rich in greens and low in simple sugars, saturated fats, processed and red meats were felt to promote long term health. Paul Agarwal , PhD of Rush University in Chicago and associates just that problem with respect to development of Alzheimer’s dementia. Their research was published in the Journal of Neurology.

Agarwal and colleagues compiled data from the Rush Memory and Aging Project which is a study of older adults who agreed to an annual physical evaluation and to donating their brains for evaluation after their death. Their study looked at 581 senior citizens with a mean age of 84 years for their first dietary assessment and a mean age of 91 at the time of death. 73% of the participants were women with all patients followed for about 6.8 years. Prior to their deaths, 38.5 % of the participants were diagnosed with clinical dementia with 66% having a pathological diagnosis of Alzheimer’s Disease at autopsy.

The authors studied how closely the participants followed a healthy Mediterranean Diet which recommends vegetables, fruits and three or more servings of fish per week or a MIND Diet which encourages green leafy vegetables, berries as opposed to fruit and one or more servings of fish a week. Both programs recommend a limited amount of wine.

The autopsies revealed that those individuals who had the most consumption of green leafy vegetables, seven or more servings per week, had less autopsy Alzheimer’s pathology than those who ate only one or two servings per week. Those who ate more green leafy vegetables had less beta amyloid in their brains a compound associated with Alzheimer’s Disease. There was no association with phosphorylation tau protein tangles. The study showed that elderly individuals following either a Mediterranean Diet or MIND Diet exhibit a lower burden of Alzheimer’s pathology at autopsy. It supports physicians, dietitians and public health officials encouraging healthy eating as a way to limit your risks of developing dementia.

Respiratory Syncytial Virus in Adults & a New Vaccine

Respiratory Syncytial Virus (RSV) produces cold like symptoms in most adults as an upper respiratory tract infection. It usually is seasonal causing infections in the community between October until May mirroring the influenza season. Most individuals start contracting RSV infections as a child with cold and cough type symptoms.  No immunity is conferred by this previous infection. In adults over age 50, and those with pulmonary diseases and or immunosuppression, we are at risk of developing severe lower respiratory tract infections (LRTI). In most pre-pandemic years, almost 35,000 adults over 50 are hospitalized with severe lower respiratory tract infection due to RSV and 6 – 8% of them die.

To prevent these hospitalizations and deaths, researchers have developed an effective RSV vaccine. The vaccine has been studied in 25,000 adult participants living in 17 different nations. The volunteers receiving the vaccine did not know if they were receiving a placebo or the vaccine. The researchers administering the vaccine did not know if they were administering a placebo or the vaccine.

The results of the study were published after peer review in the New England Journal of Medicine during the second week in February.  The vaccine prevented lower respiratory tract disease in 80% of the vaccine recipients and was 94% effective against severe disease. The study was a Phase III trial and there were few adverse effects.  It is anticipated that the vaccine will be commercially available next fall. 

There is a strong possibility that between the new COVID-19 boosters in development, the quadrivalent influenza vaccines and the new RSV vaccine we can greatly reduce the number of adult lung infections and hospitalizations that overwhelmed the health care system the last three years.

New Guidelines for Blood Pressure Control from the American Academy of Family Practice (AAFP)

When I completed my residency in internal medicine and sat for my board certification exam in internal medicine, guidelines called for physicians to keep patients blood pressure below 140/90. Those numbers have changed in recent years with any readings above 120/70 being labeled “pre-hypertension” instead of just plain old normal blood pressure.

In 2017, based on the SPRINT Study , the American Heart Association set a limit of 130/80 as the new normal. This study looked primarily at patients already diagnosed with arteriosclerotic cardiovascular disease and those at high risk of developing it.

To reach those levels it required adding an average of one more medicine to a person’s drug list. With more medicine came more adverse effects, more drug/drug interactions and more expenses for the patients. 

Using the statistics from the SPRINT study, the AAFP concluded that with the lower blood pressure guidelines there was no difference in mortality or number of strokes but a slight decrease in heart attacks. They weighed the pros and cons of that approach recognizing the study participants already had heart disease, or were well on their way to developing it, and came out with the new guidelines.

The AAFP is strongly recommending a BP goal of <140/90 in adults <60 years of age and <150/90 in seniors over 60 years of age. These higher numbers for seniors are more in line with what the neurologic medical community was suggesting so that blood perfusion of the brain would be adequate.  The AAFP went on to say that physicians should discuss with their patients the lower risk of heart attack in younger patients and share decision making with them on how aggressively to lower their blood pressure. 

The American College of Physicians (ACP) and American Board of Internal Medicine (ABIM) have yet to formally comment on these new suggested guidelines but they make great sense to me. Shooting for lower levels has repeatedly resulted in older patients developing complications of too much medication.

New Guidelines for Preventing Transmission of Infections in Medical Settings

Transmission of infections in a hospital or medical setting is now subject to a new set of directives recently published in the journal Infection Control & Hospital Epidemiology. The guidelines were created and agreed upon by The Society for Healthcare Epidemiology, the Infectious Diseases Society of America, The Association for Professionals in Infection Control and Epidemiology, The American Hospital Association and the Joint Committee on Accreditation of Hospitals. The CDC participated in the development of these guidelines as well. The recommendations follow:

1. Healthcare workers should cut their fingernails so they don’t extend beyond the fingertips and their color should be natural.
2. Alcohol based sanitizers should be used to cleanse your hands if treating patients. Too much hand washing between patients can lead to dry and cracked skin which can result in cuts and bruises and, ultimately, infections which can be transmitted.
3. Hand sanitizers in hospitals should be located both inside and outside patient rooms.
4. Certain hand cleansing stations should have their basins reserved for hand washing only, not for dumping of other fluids. Use a toilet or dedicated receptacle for all other fluids. Studies have shown that biofilm develops in these drainage systems that multiple fluids poured down them  can be the source of serious drug resistant bacterial growth.
5. Cleaning of the hand washing basins and fluid receptacles should be done with products especially approved by the Environmental Protective Agency for prevention of biofilm. The common practice of dumping some bleach down the drain is just not effective.

Lead author of the study Janet B Glowicz , PhD, RN of the CDC noted that dumping fluids down the same drains as hand washing created biofilms that led to the development of drug resistant bacteria. She additionally pointed out that vigorous and aggressive hand washing with soap and water led to dry skin and skin injury leading to infection and transmission of pathogens. This form of transmission was seen more often in skilled nursing facilities and senior homes. She suggested using alcohol based hand sanitizing solutions instead which,” kills more bugs than hand-washing removes”.

The guidelines are usually reviewed and updated every five years, but the pandemic delayed that process in recent years.

Connection Between Air Pollution & Loss of Smell?

In recent years, medical researchers have explored the possibility that loss of smell is one of the early signs of developing dementia or cognitive dysfunction. Several recent research studies have evaluated whether air pollution is a major cause of loss of smell (anosmia) and possibly dementia.  Our sense of smell is dependent on the olfactory bulbs which are nerve rich and sit on the underside of the brain.

Air pollution from the burning of carbon-based fuels produces microscopic particles known as small airborne pollution particles (PM2.5). These contaminants containing minute metal particles gain access to the brain through the olfactory bulbs and have been shown to result in producing plaque in the brain associated with dementia.

There are few studies looking at the quantity of PM2.5 particles in the air in a community and loss of smell. In 2006 a study performed in Mexico City, known for its poor air quality, revealed that its occupants smell was significantly worse than Mexicans of similar age living in less polluted rural areas.

When a large number of residents of Baltimore were discovered to have anosmia researchers investigated the quality of the air and its relationship to loss of smell. To evaluate this problem, research epidemiologist Zhenyu Zhang looked at air pollution levels in the Baltimore area using 2,690 patient records from visits to the Johns Hopkins Medical Center. The rate of loss of smell was noted to be significantly higher  in patients who lived in the most polluted areas with the highest number of PM2.5 particles. The loss of smell in 20% of this patient population was much higher than expected when they matched it against similar age groups with similar body types and similar smoking history. Yes, smoking leads to an increased risk of loss of smell as well.

In a study in Northern Italy, the smell of teenagers was put to the test. Those that lived in neighborhoods with high levels of nitrogen dioxide had a less sensitive sense of smells. Nitrogen dioxide is a product of the burning of fossil fuels.

Burning fossil fuels can also produce particles far smaller than PM2.5 particles which enter the brain through the olfactory bulb. A study in Britain looking at autopsies in patients from highly air polluted communities found minute metal particles in the brains of patients. According to some studies, air pollution contributes to 25% of all heart and lung related deaths in addition to its known relationship to stroke.

The World Health Organization (“WHO”) recognized the effect of air pollution, loss of smell and increased risk of death and lowered its acceptable rate of PM2.5 particles from 10 to 5 micrograms per cubic meter. The hope is that with less pollution there will be less loss of smell and less loss of life.  The WHO’s efforts have been hampered by global warming, multiple major worldwide wildfires and, for economic reasons, a slow conversion from fossil fuels to more environmentally friendly methods of producing energy.

With loss of smell now being associated with dementia, heart, lung and cerebrovascular disease, plus increased risks of depression and anxiety, it may be time to rethink our economic priorities.

Changes in Alcohol Consumptions & Dementia Risk

The coronavirus pandemic has been accompanied by an increase in the purchase and consumption of alcoholic beverages. A recent review of the medical literature being covered by the general media talks about even small amounts of alcohol being detrimental to brain health. To counter that opinion, an article appeared in this month JAMA Network Neurology section evaluating the effect of alcohol consumption over a prolonged period of time and examining its effect on the likelihood of developing  dementias including Alzheimer’s disease, vascular dementia and other dementias.

The data was obtained in South Korea from their National Health Service data bank. Almost four million patients with a mean age of 55 were followed from 2009 until 2018. They were categorized into nondrinkers of alcohol, mild drinkers (< 15 grams per day) , moderate drinkers (15-29.9 g per day) or heavy drinkers (>30 grams per day). On the basis of the patients reported, alcohol consumption changes over that time period were reclassified into nondrinkers, quitters, reducers, sustainers and increasers.

Based on recent reports of even mild drinking causing brain damage, the results were surprising. Heavy drinking was associated with an increased risk of dementia as expected . Mild to moderate drinking was associated with a decreased risk of developing dementia compared to sustained nondrinking.  Heavy drinkers who reduced their intake showed a diminished risk of dementia as did nondrinkers who began to drink lightly regularly. 

This South Korean study seems to show that drinking alcohol in moderation doesn’t increase your chances of developing dementia. Its unclear whether this data applies to the US population or is there something different in that culture that protects South Koreans compared to Americans? It certainly promotes the idea of drinking alcohol in moderation does not increase your chances of developing dementia.

Screening for Colorectal Cancer with Fecal Immunochemical Tests

Preventive medicine is now directed by guidelines on who to screen, at what ages and how often.  Both the US Preventive Task Force (USPTF) and the American College of Gastroenterology have suggested we stop performing colonoscopies on patients 75 years or older whose previous colonoscopies have been normal. This is because the possibility of perforating the colon during the procedure rises dramatically in individuals 75 years of age and older. Also, the preparation for the procedure can create problems. In addition to these reasons, many patients diagnosed with colon cancer can be treated, remain alive and functional for far longer and well past their expected survival from all health issues.

I have a significant number of patients 75 years of age who have a family history of great longevity. They argue that they do not wish to deal with advanced colorectal cancer as they age. They recognize the risks of having a screening colonoscopy but don’t wish to assume the risk of undetected colorectal malignancy.

For some we can use Cologuard which genetically evaluates the cells from the colon sloughed when we move our bowels. Many insurers will not pay the approximate $500 for Cologuard in this age group. 

A recent article in the Journal of Clinical Gastroenterology and Hepatology touted the benefits of the much less expensive fecal globulin or FIT test.  This test examines the stool specimens of patients to detect human blood. It is far more accurate than previous “stool occult blood tests”. 

The study looked at 3,369 above average risk patients aged 50 – 74 with a previous adenomatous polyp detected or with a strong family history of colorectal cancer. They administered an annual stool FIT test and then followed it with a colonoscopy at two years.

Having a negative stool FIT test correlated well with having no cancer or precancerous lesions on colonoscopy. An annual FIT stool card may be a great way to screen those 75 years of age and older for colon cancer and to extend the period of time between colonoscopies in the younger age groups.  Ask your doctor for an annual FIT stool kit to screen for colon cancer.

Time to Screen for Lung Cancer

The United States Preventive Task Force (USPTF) for years has recommended that smokers and former smokers be screened annually with a low dose CT scan of the lungs. Despite this recommendation, experts believe less than 20% of the eligible patients are actually ever screened. In recent years they lowered the entry age and the number of cigarettes smoked to widen the surveillance. If you are 50 years old with a smoking history of at least 20 pack years (calculated as number of packs smoked per day x the number of years you smoked) you should be screened until age 80.

In a recent study published in the Annals of Internal Medicine, Iakovos Toumazis, PhD, of the University of Texas MD Anderson Cancer Center in Houston proposed an alternative risk model-based screening for lung cancer that may be much more cost effective and save more lives than the current USPTF recommendations. This model will be reviewed and may supplant current recommendations.

Leica Sequist, MD, MPH, and team at the Harvard Medical School and Massachusetts General Hospital of Boston have developed a screening tool using Artificial Intelligence with a program they developed named Sybil using one Chest CT scan. Their work was published in the Journal of Clinical Oncology and was able to look at pulmonary nodules and accurately predict which of those nodules, if any, had the ability to develop into a malignancy. Currently we follow these nodules with serial CT scans over a number of years to insure stability. One CT scan exposes you to the equivalent radiation of 200 chest x- rays so being able to scan only once and predict the future saves you from additional radiation exposure. While the researchers and scientists perfect the art and skill of finding lung cancer early, we still need our patients who are 50 years old or older with a smoking history of 20 pack years or more to step up and identify themselves so we can get them screened safely. With the use of electronic health records and the high-volume patient loads seen in primary care offices daily, this information is not always obtained and or captured in the record.