Shared Decision Making. Science versus Art of Medicine.

My 80 year old patient presented with symptoms and signs of kidney failure. I hospitalized him and asked for the assistance of a kidney specialist. We notified his heart specialist as a courtesy. A complicated evaluation led to a diagnosis of an unusual vasculitis with the patient’s immune system attacking his kidney as if it was a foreign toxic invader.

Treatment, post kidney biopsy, involved administering large doses of corticosteroids followed by a chemotherapy agent called Cytoxan. Six days later it was clear that dialysis was required at least until the patient’s kidneys responded to the therapy and began working again.

You need access to large blood vessels for dialysis, so a vascular surgeon was consulted. He placed a manufactured vascular access device in the patient’s lower neck on a Monday in the operating room. The access was used later that day for a cleansing filtration procedure called plasma exchange. The patient returned to his room at dinner time with a newly swollen and painful right arm and hand on the same side as the surgical vascular access procedure.

The nurses were alarmed and paged the vascular surgeon. His after-hours calls are taken by a nurse practitioner. She was unimpressed and suggested elevating the arm. The floor nurses were not happy with that answer since they had seen blood clots form downstream from vascular access devices. They next called the nephrologist. He suggested elevation of the arm plus heat. This did not satisfy the charge nurse who requested a diagnostic Doppler ultrasound to look for a clot. The nephrologist acquiesced and it was done quickly revealing a clot or deep vein thrombosis (DVT) in an arm vein.

I am the patient’s admitting physician and attending physician (it is unclear to me what the difference is) but I was surprised I did not receive the first or second call regarding the swollen arm. I was the first however to receive a call with the result. My first knowledge that a problem was occurring came when an RN called, “Dr. Reznick, the patient in 803 came back from dialysis with a painful swollen right arm and hand. The vascular surgeon was called but his covering nurse practitioner wasn’t concerned. The nephrologist ordered the test after we encouraged him to. There is a clot in the right brachial vein. What should we do?”

This was a new complication occurring to a frightened patient just returning from surgery, plasma exchange and hemodialysis for the first time to treat a rare aggressive disease he and his children had never heard of. One of my cardinal rules of practice is when in doubt listen to the patient, take a thorough history of the events, examine the involved body parts, look at the diagnostic studies with the radiologist and explain it all to the patient and family. I changed my leisure clothes to my doctor clothes and headed to the hospital delaying dinner, something my wife is incredibly understanding and tolerant of.

One of the perks of teaching medical students is being provided free and total access to the medical literature using the school’s library and subscription access. I searched for anything related to upper extremity deep vein thrombosis after establishing vascular access and related to his vasculitis. Three items popped up including recommendations and guidelines for diagnosis and treatment from the American College of Cardiology and the American College of Thoracic Surgeons all within the last six months. They both suggested the same things, use intravenous blood thinners for five to seven days then oral anticoagulants for three to six months or until the vascular access is removed. The risk of the blood clot traveling to the lungs is lower than in leg and pelvic DVTs but it is still 5 – 6%.

I read this while the radiologist accessed the films and reviewed them with me. Next stop was the eighth floor where the patient and his out of town visiting adult child were. I asked them what happened. They showed me the warm swollen arm and hand. I checked for pulses which were present and then color and neurological sensation which were normal. I explained that when vascular access is inserted in the large neck veins it can increase the risk of a clot forming in the arm veins resulting in arm and hand swelling. I explained that the chances of a clot traveling back to his heart and out to his lung were 5 – 6% and significantly less than DVTs in leg or pelvic veins. The treatment was explained. His nephrologist concurred as did the cardiologist. Heparin was begun.

With elevation and soaks the swelling was down by morning. He returned from dialysis that afternoon with his chin and neck all black and blue. He was bleeding profusely from the upper portion of the surgical access site. Nurses were applying compression to the area after the blood thinner was stopped and it continued to bleed. Vascular surgery was furious that heparin or any blood thinner was used for the clot.

Repeated phone calls to the vascular surgeon resulted in him angrily arriving much later placing six sutures to stop the bleeding. Heparin can lower platelet counts when antibodies to heparin cross react with platelets. His platelet count of 80,000 was sufficient to prevent bleeding. A blood test for heparin induced thrombocytopenia was drawn and he received two more units of blood products to replace what he lost. After stabilizing the patient, we realized his drop in platelets was due to the Cytoxan having its peak effect not heparin.

The patient had no further bruising or bleeding. He was dialyzed or had plasma exchange on alternating days for another week. The nephrologist wanted this done in the hospital not as an outpatient. It took one week for the reference lab to return the negative HIT (heparin induced thrombocytopenia) results clearing the heparin of causing the bleeding and bruises.

Prior to discharge I reviewed the long term oral anticoagulation recommendations of the American College of Cardiology and Thoracic Surgeons with the patient, nephrologist, cardiologist and hematologist. The nephrologist was comfortable with administering a kidney failure lower dose of eliquis. The vascular surgeon and cardiologist felt it was not necessary. The hematologist initially agreed then changed his mind. I asked each of the naysayers to explain to me how this patient differed from the patients in the many studies who comprised the data for the recommendations? They said he did not. They said they had a feeling and discussed “the art of medicine in addition to the science”.

In a rare vasculitis disease which few of us have seen frequently, I prefer the data in multiple studies to one’s clinical intuition. At discharge, I prescribed the oral blood thinner. I reviewed the pros and cons of the drug. The patient and daughter told me that based on the ambivalence of the hematologist he would stick with his aspirin rather than the oral anticoagulant.

Shared decision making appropriately allows patients to decide for themselves. If the patient develops pleuritic chest pain coughing up blood with shortness of breath from a pulmonary embolus, I will be called to provide care not my colleagues because specialists don’t admit.

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Coffee and the Healthy Heart

Two German biologists are stating there is sufficient data to claim that four cups of caffeinated coffee is the optimal daily dosage to maintain a healthy heart. Their findings were published in Plos Biology and summarized in Inverse Magazine. The scientists cite past warnings by public health officials of the danger of caffeine when given to people with heart conditions. Quite the contrary. They believe that up to four cups of coffee per day are actually therapeutic for the heart.

In their research they noted caffeine helps a protein called “p27” enter the energy producing mitochondria of heart cells making them function more efficiently. They experimented with rats comparing the mitochondrial function of old rats and young rats. When they injected the older rats with the caffeine equivalent of four cups of coffee, their aging mitochondria performed at the level of young rats’ mitochondria. They then experimentally caused the older rats to have a heart attack or myocardial infarction. Half of these heart damaged rats were injected with the equivalent of four cups of coffee and their heart cells repaired themselves at a far more rapid rate than those not exposed to that dose of coffee and caffeine.

The researchers conclude that four cups of coffee is probably the optimal daily dosage of coffee for a healthy heart. They caution that certain patients, especially those with malignant tumors, should probably avoid that much coffee because it may promote growth of blood vessels to the tumors. They additionally caution against using caffeine pills or energy drinks because their research was done with coffee.

Coffee in moderation is probably not harmful for any human adult.

Keep in mind, this biologic evidence was obtained in rats not human beings. Fortunately, I have not seen rats breaking into my local Dunkin Donuts and Starbucks craving a lifesaving nutrient.

Coffee has been associated with preventing cognitive dysfunction, preventing diabetes and now keeping your heart healthy. If you enjoy coffee, drinking it in moderation makes sense to me.

The American Cancer Society and Colorectal Cancer Screening

Colorectal cancer is the fourth most common cancer with 140,000 diagnoses in the nation annually. It causes 50,000 deaths per year and is the number two cause of death due to cancer.

Colorectal cancer screening guidelines have called for digital rectal examinations beginning at age 40 and colonoscopies at age 50 in low risk individuals. An aggressive public awareness campaign has resulted in a marked decrease in deaths from this disease in men and women over age 65.

The same cannot be said for men and women younger than 55 years old where there is an increased incidence of colorectal cancer by 51% with an increased mortality of 11%. Experts believe the increase may be due to lifestyle issues including tobacco and alcohol usage, obesity, ingestion of processed meats and poorer sleep habits.

To combat this increase, the American Cancer Society has changed its recommendations on screening suggesting that at age 45 we give patients the option of:

  • Fecal immunochemical test yearly
  • Fecal Occult Blood High Sensitivity Guaiac Based Yearly
  • Stool DNA Test (e.g., Cologuard) every 3 years
  • CT Scan Virtual Colonoscopy every 5 years
  • Flexible Sigmoidoscopy every 5 years
  • Colonoscopy every 10 years.

Their position paper points out that people of color, American Indians and Alaskan natives have a higher incidence of colon cancer and mortality than other populations.  Therefore, these groups should be screened more diligently. They additionally note that they discourage screening in adults over the age of 85 years old. This decision should be individualized based on the patient’s health and expected independent longevity.

As a practicing physician these are sensible guidelines. The CT Virtual Colonoscopy involves a large X irradiation exposure and necessitates a pre- procedure prep. Cologuard and DNA testing misses few malignancies but has shown many false positives necessitating a colonoscopy. Both CT Virtual Colonoscopy and Cologuard may not be covered by your insurer, and they are expensive, so consider the cost in your choice of screening.

I still believe Flexible Sigmoidoscopy must be combined with the Fecal Occult Blood High Sensitivity Testing and prepping.  Looking at only part of the colon makes little sense to me in screening.

Colonoscopy is still the gold standard for detecting colorectal cancer.

Allergies Worsening Due to Climate Change

The American Academy of Allergy, Asthma and Immunology and the World Asthma Organization just concluded their joint congress in Orlando, Florida. One of the topics of concern is how climate change is making everyone’s allergy symptoms much worse.

We read about more powerful hurricanes and cyclones, seasonal tornadoes occurring out of season, horrible beach erosion and flooding due to large volume rains, lack of rain causing poor harvests leading to waves of migration for survival for animals and humans. Climate change also exacerbates allergy symptoms. Nelson A. Rosario, MD, PhD, professor of pediatrics at Federal University of Parana (Brazil) discussed longer pollen season and increased allergens caused by fallen trees and ripped up plants, mold growing following flooding and irritants in the air due to wildfires. An international survey in 2015 found that 80% of rhinitis patients blamed their symptom exacerbations on climate change items. Pollen seasons have more than doubled in some areas.

The argument should not be about whether climate change is due to cyclical planetary changes or man-made pollutants. It should be about what we can do as a society to maintain economic growth while limiting man made contribution to adverse climate changes. The health and survival consequences of not addressing this issue will ultimately involve our survival as a species.

Lack of Vaccination Coverage in the Medical Office

This week a patient, going on a foreign trip, was required to fill out a vaccination and immunization record to obtain a visa. To his dismay he discovered his records were not available. On further questioning he realized his vaccinations were done at retail clinics and pharmacies up and down the Eastern seaboard. Yes, he had requested a record of the vaccination be sent to the office but it never arrived.

I am a firm believer in the recommendation of the CDC, American College of Physicians and Advisory Council on Immunization Practices. Their literature is displayed in my office and available as a resource to my patients. I find it abhorrent that CMS, through its Medicare Part D program, will pay for the shingles shots (Zostavax and Shingrix) and the pneumonia series (Prevnar 13 and Pneumovax 23) at the pharmacy but not at a doctor’s office. The pharmacies use these vaccinations as loss leaders to get individuals into the store hoping that they will buy additional items while there.

As a general internist and practitioner of adult medicine, I too use these vaccinations as a “loss leader.” When patients call for a vaccination and have not been seen in a long while we encourage an appointment. We check on prevention items recommended by the ACP. the AAFP and the USPTF and make sure the patients are current on mammograms, HPV or Pap testing, colonoscopies, eye exams, hearing evaluations, skin and body checkups and other essential health items. We make little or no money on vaccinations or immunizations but like the idea that once a patient is here we can provide a gentle reminder about those health tasks we all need to follow up on with some regularity.

I like the idea of making vaccinations and immunizations more convenient for patients. I just believe the same payment should be made if the patient is in your office or in the pharmacy. In addition, the law should require the pharmacy to send a record of the vaccination to the patient’s physician so we can have immunization records readily available.

The ACP, AMA, American College of Physicians and American Academy of Family Practitioners should be using their influence to encourage the Center for Medicare Services (CMS) to pay for these vaccines in doctors’ offices as well as in pharmacies and retail clinics. If encouragement doesn’t work then legal action is appropriate.

The Blood Pressure Guidelines Dilemma

The American College of Cardiology and American Heart Association recently published blood pressure control guidelines that suggest we should be treating blood pressure in 25 year olds the same way we treat it in 79 year olds and older patients. If you have any cardiovascular disease, or a 10% cardiovascular risk assessment over the next few years, they want your systolic blood pressure to be less than 130. They present excellent data explaining that as the blood pressure elevates above 130, the risk of a heart attack, stroke, vascular disease or kidney disease and, ultimately, death increase. No one is arguing these facts.

The American College of Physicians (ACP) along with the American Academy of Family Physicians (AAFP) recognizes this one size fits all in blood pressure control creates many problems. As we age, our arteries become less compliant or elastic. Stiffer arteries are more difficult to assess for blood pressure value. After we have exhausted the lifestyle changes of smoking cessation, weight loss, salt restriction and increased activity to control blood pressure; we are forced to use medications. We try to use low doses of medicines to avoid the adverse effects of the pills that the higher dosages can bring.

These medicines are costly. The more we prescribe the more patients don’t take them due to the cost. The more we prescribe, the more patients forget to take multiple pills on multiple schedules of administration. If we get the patients to take the medication we run into the problem of blood pressure precipitously dropping when patients change positions from supine to sitting to standing. If we are lucky, and the patient is well hydrated, then we may only be dealing with a brief dizzy spell. In other cases, we are left treating the consequences of a fall and injury from the fall. The more we strive to control your blood pressure to the new levels with medications the more we must consider drug interactions with prescription medicines being prescribed for other health problems seen in older Americans.

At this point, experts from the ACP Policy Board and noted hypertensive experts at the University of Chicago have suggested we follow the more liberal guidelines of the ACP individualizing our care based on the patient’s health issues. Personalizing care with individual goals makes sense to me, especially in my chronically ill patients battling blood pressure, weight control, age related orthopedic issues, and age related visual and urological issues plus other problems. We strive to do that in our practice allowing the time for discussion, questions and evaluation at each visit.

Treatment of Gastroesophageal Reflux with Magnet Device

Gastroesophageal reflux disease causes heartburn and regurgitation of food and digestive enzymes. Treatment includes weight loss, wearing loose clothing not binding at the waste, dietary restriction and medications. The main class of medications used have been the protein pump inhibitors (PPI’s) such as Nexium, Protonix, Aciphex and Pepcid. Most recently this class of medications has come under major criticism from researchers believing they may be responsible for increased risk of community acquired pneumonia, malabsorption of nutrients resulting in bone disease and even dementia and cognitive decline. Physicians have been trying to limit the use of these medications but recurrent and persistent symptoms have made that very difficult.

Last month at Digestive Disease Week, a meeting sponsored by the American Association for the Study of Liver Diseases, The American Gastroenterological Association, The American Society of Gastrointestinal Endoscopy and the Society for Surgery of the Alimentary Tract; a paper was presented demonstrating the success of a magnetic band placed with laparoscopic surgery around the lower esophageal sphincter (the juncture of the esophagus and stomach).

Reginald Bell, MD of the SurgOne Foregut Institute in Denver, Colorado along with MedPage reported that at six months post procedure, 92.6% of the patients with the magnetic device LINX, had relief of regurgitant symptoms compared with 8.6 % taking a double dose of PPI’s. Only one surgical complication had occurred and it was corrected. The research was done at 22 different locations enrolling 150 patients with moderate to severe regurgitation despite once-daily use of a PPI treatment.

The improvement numbers are dramatic and if this stands over time will change the way we treat this disease. The publication did not reveal the cost of LINX and we certainly want to observe these patients for more than six months before endorsing a new and promising treatment.