Scientists Develop Rapid Susceptibility Tests for Urinary Tract Infections

In my geriatric patients, recurrent urinary tract infections and conditions mimicking them pop up frequently. Patients young and old find it inconvenient to come to the office to provide a specimen to analyze whether or not an infection has occurred and what is causing it. You often need to send the specimen off to the lab to culture the offending bacteria and then wait further for the lab to determine what antibiotic if any will work against that invader. As clinicians, if we suspect an infection and the in-office or clinic urine specimen looks infected, we treat with the antibiotics most likely to cure until we actually get the official reports back from the lab.

An esteemed panel of health care experts has recommended something different -suggesting that when symptoms of a urinary tract infection develop patients be prescribed a three day course of antibiotics without an exam or urinalysis or pre-antibiotic treatment urine for culture and sensitivity. This is all part of the 21st Century movement for less costly, less time consuming, more convenient self-diagnosis and care using your high tech apps to diagnose and treat your problem.

In my patient population many of the elderly patients use so many antibiotics so many times for presumed urine infections that we are often dealing with multi drug resistant bacteria requiring intravenous treatment with complex medications to cure the problem.

Scientists announced recently in the journal, Science Translational Medicine, that they have developed a rapid 30 minute DNA test that will allow us to determine the susceptibility of the offending organism quickly. The successful study has led to the beginning of developing a commercial variety of the test expected to be available in three years. If it works and is affordable it will make outpatient treatment of urinary tract infections far more accurate and efficient.

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Inflammation as a Cause of Heart Attacks and Strokes

Years ago I attended a series of lectures sponsored by the Cleveland Clinic to promote its proprietary lab tests that were geared to detect previously undetectable causes of heart attacks and strokes. A cardiologist at Cleveland Clinic, along with a research nurse out of Emory University Hospital and Medical Center, noted that 50% of the men having heart attacks and strokes were within the recommended life and health guidelines. They didn’t smoke, their blood pressures were controlled, they had lipids within the recommended guidelines and their weight was appropriate – as was their activity level.

They unofficially dubbed it the Supermen study and showed that by reducing “inflammation” they could reduce the number of heart attacks and strokes. They concentrated on periodontal disease and rheumatologic diseases as sources of inflammation. They believed that angina and heart attacks and strokes did not occur because a blood vessel gradually narrowed much like a plumbing pipe clogged with hair and debris. They felt that soft lipid plaque under the surface in vehicles dubbed “foam cells” ruptured through the blood vessel wall into the lumen through the endothelial lining under the direction of inflammation in the body.

This breakthrough into the blood carrying portion of the blood vessel was perceived as a fresh cut or wound which was bleeding. The body’s natural response was to try and stop the bleeding by creating a clot. This clot occurred quickly in a small vessel and every living item downstream, not supplied by a collateral blood vessel, died from lack of oxygen and fuel to function. They treated the identifiable inflammation and felt that statin medications (Lipitor, Zocor, Pravachol, Crestor , Livalo and the generics) had an of- label quality that reduced inflammation as well as lowered the cholesterol.

I bought into that theory and incorporated these blood tests into the patient population most at risk and the appropriate age where prevention would make a major difference. Tests like hsCRP, Myeloperoxidase, Apo-B and others were used for screening. Finding the inflammation and treating it for men who met the definition for entry into the Supermen study was far more difficult. The whole theory of inflammation causing acute cardiac and cerebrovascular events was treated much like climate change, genetically modified foods and even vaccinations with a large degree of community doubt.

Last week at a major European Cardiology meeting the CANTOS (Canakinumab Anti-inflammatory Thrombosis Outcomes Study) showed that by administering an anti- inflammatory medicine for three plus years at an appropriate dosage, we could reduce the number of heart attacks and strokes significantly. Using a monoclonal antibody, “Canakinumab” at 150 mg every third month they treated inflammation and reduced the number of events. The downside was the annual cost of this medicine currently stands at about $200,000 per year making it unavailable for most of us.

The surprising and startling finding was that it reduced lung cancers by 70% and other malignancies as well. The true finding in this study may be its use as a cancer weapon in the future. The study truly opened the door for research into new and less expensive approaches to treating inflammation. It validated inflammation as a pathway to vascular disease. Now we need to find a way to make that treatment affordable to all.

Extreme Exercise Tied to Gut Damage

I was out doing my morning two mile trot on an unseasonably cool late spring morning in South Florida. The crispness of the day, coupled with unexplained lack of my normal warm up aches and pains made me particularly frisky. I had walked the dog for a few miles slowly, then engaged in my normal pre-run stretching routine and felt unusually energetic and fluid. I was enjoying the outdoors and weather, while listening to music on my play list and struggling to stay within the parameters of speed, pace, and target heart rate appropriate for a 67 year old man. The inner competitor within me was screaming, “You feel great, go for it.” Moderation and common sense are always the great traits to keep exercising and not injured. The inner stupid competitor in me said pick up the pace. I did pick up the pace. I completed my course far quicker than usual. I performed my cool down and stretching routine and was feeling pretty cocky about doing more than I should when I heard that rumble in my gut and saw the distention begin. The distention was followed by cramps, gas and profuse uncomfortable loose stools for several hours. My gut was sore and my appetite was gone.

I mention this after reading an article review in MedPage Today about a publication in the journal Alimentary Pharmacology and Therapeutics published by Ricardo J.S. Costa, M.D., of Monash University in Victoria, Australia. He and his colleagues showed that exercise intensity was a main regulator of gastric emptying rate. Higher intensity meant causing more disturbances in gastric motility. High intensity exercise at a rate you are not used to for a period of time longer than you usually exercise leads to gut problems including all the issues I experienced. Low to moderate physical activity was found to be beneficial especially to patients, like myself, suffering over the years from irritable bowel syndrome.

The researchers found that ultra- endurance athletes competing in hot ambient temperatures running in multi stage continuous 24 hour marathons were far more likely to develop exercise associated GI symptoms than individuals running a less intense half marathon. The results are fairly clear for us non ultra-endurance athletes. There is great wisdom in regular moderate exercise to keep your effort within the parameters your physician and trainer recommend based on your age and physical training. Even if it’s a cool crisp day and you feel that extra surge of adrenaline and competitiveness, moderation is best for your health and your gut. I hope the competitor in me remembers that the next time the urge to push the limit pops up.

Coffee Consumption Lowers Mortality Risk

The online edition of the Annals of Internal Medicine, July 11, 2017 edition published an article from MJ Gunter using data from the European Prospective Investigation into Cancer and Nutrition that concluded that coffee consumption lowered patient mortality. The study looked at more than 520,000 patients from 10 different countries that were followed for 16.4 years. In a side study they looked at a group of 14, 800 patients and examined the correlation between coffee consumption and biomarkers of liver inflammation, function and health.

Patients who drank the most coffee had statistically significant lower all-cause mortality than individuals who did not consume coffee.  Patients in the highest group of coffee consumption tended to have significantly lower risk for mortality related to digestive diseases. Women coffee drinkers had a lower risk for cerebrovascular disease mortality and circulatory disease mortality but were at higher risk for ovarian cancer related mortality.

The researchers concluded, “Coffee drinking was associated with reduced risk for death from various causes.”

I will enjoy my coffee even more now. If only I could lay off the bagels and donuts that go with it.

Low Level Air Pollution Still Kills

These are turbulent controversial times with the United States not honoring its commitment to the Paris Climate Accord which was supposed to reduce carbon emissions into the atmosphere and help control pollution. Passions are high on both sides of the issues with coal mining and oil industry lobbyists lining up against those who believe those products accelerate global warming. It comes at a time when an ice mass the size of the state of Delaware broke off from its ice shelf home in Antarctica and floated out to sea either due to global warming or normal calving of glaciers and ice masses.

These passion provoking news stories come at the same time a major environmental study was published in the New England Journal of Medicine stating that low levels of atmospheric pollutants, well under the government’s current permitted levels, are killing 12,000 people per year over the age of 65. The study, reported by Qian Di. MS of Harvard University and colleagues, looked at 60 million Medicare beneficiaries between the years 2002-2012. They examined the levels of airborne fine particulate matter and ozone. Each small increase of particulate matter of 10ug/m3 was associated with a 7.3% increase in all-cause mortality. They concluded that there was no truly safe level of particulate matter with mortality increasing in this age group even at levels currently considered safe by current standards

When they looked at ozone levels they noted that for each increase of one part per billion, the mortality rate increase was about 1.1%. Males, blacks and Medicaid-eligible individuals had the highest risk of death from increased ozone.

According to the article’s author, “The message is clear. Air pollution kills people, even below current National Ambient Air Quality standards. The current air quality standard is not stringent enough to protect human health.” His statements are extremely meaningful since the current Trump administration and EPA director are seeking to lower the air quality standards imposed by previous Republican and Democratic administrations.

Whether you believe the planet is warming due to a natural occurring process, or due to interference by human production of pollutants, we all recognize our climate is changing. Anything we can reasonably do to slow the process down is worth considering so that our children and grandchildren have a planet to safely live on.

Now with this article in the New England Journal of Medicine it is clear we do not have to wait for massive global climate changes to kill us off quickly. Air pollution is already doing that job at levels once considered safe and tolerable. To relax the air pollution rules and regulations is just inviting more respiratory illness and death in the senior citizen population.

Write your Congressperson and Senator and protest relaxation of the EPA air pollution regulations to protect you. Maybe killing off the elderly with air pollution and global warming is in the global plan of our leaders to save money on elder health care. If you kill us you don’t have to spend money caring for us.

PPI Use and Death Risk

In recent weeks we have seen articles linking the long term use of proton pump inhibitors such as Nexium (esomeprazole), Protonix ( Pantoprazole), Aciphex (Rabeprazole), Prilosec ( Omeprazole) with an increased risk of community acquired pneumonia, kidney disease, bone disease, cognitive dysfunction and increased risk of clostridia difficile infection (antibiotic related colitis). These drugs are commonly used short-term for the treatment of ulcers, gastro esophageal reflux disease, Barrett’s Esophagus, upper GI bleeding and H Pylori infections.

Often, after the prescribed treatment period, physicians try to discontinue the use of PPI’s but the patients have a return of their symptoms. With these medications now being sold over the counter, it is very difficult to get a symptomatic individual to curtail therapy even if the long-term risk is daunting.

I often attempt to switch patients to “old fashioned” antacids such as Tums, Rolaids, Mylanta, Gaviscon or even the H2 receptor blockers such as Tagamet and Zantac (Cimetidine and Ranitidine). All too frequently the response is that “my symptoms returned and only get better with the PPI.”

A study published in the British Medical Journal looked at data from the Veterans Administration data base for a period of two years, and selected a representative group of PPI users and non-users. They then followed them for 7-8 years.

Patients taking PPI drugs regularly had a 25% increased risk of death. There was no apparent reason why these medications led to a higher death risk. Further studies will be needed. The conclusion is take them for as short a period of time as possible.

Large Health System Care in the 21st Century

My 74 year old obese, poorly controlled diabetic patient with high blood pressure, high cholesterol, coronary artery disease, asthma, obstructive sleep apnea has been difficult to motivate to improve his lifestyle and his health. He is bright, sweet and caring but just not very disciplined.

At each office visit we review his medications, review his dietary habits and go through the check list of checkups for diabetic complications including regular ophthalmology exams and podiatric exams to prevent diabetic retinopathy and foot skin breakdown and infection. His spouse is always present and we discuss seeing his endocrinologist regularly and a dietitian who specializes in diabetes care all the time. To no avail, I have suggested seeing a psychologist.

Three months ago, two weeks after his last office visit, his wife self-referred him to our local community hospital Emergency Department for a small ulcer at the base of his toe. He was seen, treated and referred to that hospital’s therapy and wound care center. I was listed as his primary care doctor. He was seen by the ED but I was not called or informed of the visit. He has continued to see wound care regularly but, to date, I have received no notification of the problem, the visits, the ongoing therapy, the prognosis and/or the results.

I became aware of the situation when at the end of a long day an emergency department physician contacted me. “Dr. Reznick, we have your patient here. He was seen in the wound care center earlier today for ongoing treatment of an enlarging diabetic foot ulcer. The podiatrist debrided the wound surgically then put a bandage on it and a fiberglass cast. One hour later the patient called the wound care center complaining of shaking chills and rigors. He was told that no one was available at wound care to see him and was referred to the emergency department. He is currently running a low grade fever of 100.8 with a mild elevation of his white blood cell count and says his leg feels the way it did when he had a cellulitis infection. His blood sugar is 256. He is well hydrated. I plan to culture him up, start him on oral antibiotics and refer him back to you for follow up tomorrow if that is ok.”

I suggested he open the cast, take down the bandage dressing and observe the wound and culture it first. He told me he would call the podiatrist from wound care because he didn’t want to “mess with” the cast.

Twenty minutes later he called back, “The patient is refusing to go home. He wishes to be admitted to the private suites section of the hospital. When I told this to the podiatrist, he said he would come in tomorrow to look at the leg.” I asked the ED physician to cut off the cast and remove the bandage and I was on my way in to see the patient. I asked him if he felt the patient needed to stay. He replied, “The patient wants to be admitted and I do not want him to give me a poor patient satisfaction report, so yes he needs to be admitted. The patient satisfaction report may not be important to you private physicians but it could cost me pay and my job.”

There is nothing like assuming the care of a problem that occurred within a large health care system that is clearly interested in generating revenue for services rendered but not necessarily providing continuity of care and communication with its staff so that the patient is treated well. It is irritating and frustrating to not be included in the health care process but called in out of the bullpen after hours for something that should not have occurred in the first place.

When I arrived in the ED and went down to the patient’s room I was greeted by the patient’s wife. The cast was still on. I paged the podiatrist and reached him ultimately by cell phone. I politely made it clear that I expected him to come in now, remove the cast and take the bandage off so I and the infectious disease expert I was consulting could observe the wound, culture it and make a gram stained slide so we could choose the correct antibiotics for this situation. “Why,” he asked suggesting that the culture would show a conglomerate of multiple organisms. “Because infectious disease will want a culture and a gram stain unless they suddenly have started to operate differently and because it is good medicine.” I took a thorough history using my office notes as well and was disappointed and surprised to learn that although at each visit he confirmed that he was seeing his endocrinologist and spoke to him, he actually had not been to his office in over a year.

The admission process takes well over an hour for me. Writing an admission note and entering orders and medications on the hospitals computer order entry system is slow and cumbersome.

At the completion of the process I walked into the room and reviewed my findings and suggestions and asked if the patient had any questions. His wife had one question. “Three months ago at wound care I showed” the doctors an article about the benefits of using a product called Duoderm on diabetic foot ulcers. I asked if it would be helpful for my husband. They said it would be beneficial but it was too expensive and they were not allowed to use it.” She asked them to write out a prescription for it and she would pay for it privately if they would use it. They refused saying they were not allowed to use non formulary items. I told her I was sorry and suggested that in the future if she runs into a roadblock she should call me.

I admitted the patient to the hospital, cultured his blood and urine and asked for help from an experienced endocrinologist and infectious disease expert with his antibiotics and diabetic care. I returned several hours later to find the cast off, the wound bandaged but no wound culture obtained by the podiatrist from our hospital wound care center. I asked the nurse for sterile gloves, supplies to create a small sterile field and culture tubes when the infectious disease physician walked in and relieved me of the task. We used the gram stain of the specimen to help direct initial antibiotic choices while awaiting the culture results. A subsequent MRI of his foot revealed that the infection had spread to the base of the bone in his big toe. This will now require 6-8 weeks of intravenous antibiotic therapy to try and save the foot.

I had been a patient at the same not-for-profit local hospital several weeks before for an inpatient urologic procedure. When I woke up from anesthesia with an indwelling urinary catheter in place, the surgeon was there to report on the procedure. “It went well “he said, “but the damn cheap products the hospital is supplying us with make it highly likely that the catheter will kink up on you and put you into urinary retention. I should have brought some supplies from my office because this doesn’t occur with the products I buy and the hospital used to buy.” The catheter did kink numerous times requiring intervention and eventually a late night visit to his office for him to change catheters and leg bag so that the urinary drainage was not obstructed. When it is kinked and urinary flow is obstructed and your bladder fills, it is very uncomfortable.

As a board certified internist with experience in geriatrics and hospital staff privileges for 38 years it is disconcerting and frustrating to see the direction of hospital medicine. It is unclear to me if using Duoderm on my patient’s foot ulcer would have prevented his failure to heal and bone infection. It is clear that his wound caregivers thought highly of the product but were clearly intimidated to write a script for it even if the patient paid for it themselves.

It is sad that the ED physician wouldn’t justify his decision to admit the patient to me by simply saying his clinical situation warrants it. To be afraid of patient satisfaction rating as the reason for suggesting he stay is disheartening. To purchase less expensive urinary catheters which the surgeons clearly know is problematic and add pain, discomfort and additional costs for physician and nursing time is inexcusable.

If this is the direction hospital care is travelling I feel sorry for our patient population. I will address these issues with hospital administration and our medical staff officers directly for whatever it is worth.