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.

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.

Dementia Prevention Information Is Confusing

Part of the responsibility of being a physician is keeping up with the medical literature. I subscribe to numerous print and on line journals and read volumes each day. My professional email is littered with summaries of journals. As the baby boomers age and 10,000 of them are enrolled in Medicare per day the emphasis on preventing and treating cognitive impairment leads to volumes of studies and reports daily. To say it is confusing is an understatement.

A recent report from the National Academies of Sciences, Engineering and Medicine has painted a more optimistic picture of potential interventions in its current report as compared to its 2010 report. In the 2010 report they had nothing to be positive about. In the current report that negativism has changed to “inconclusive but encouraging “evidence of staving off cognitive decline. Within the geriatric care community this group’s opinion is still contested by the National Institute of Aging and the Agency for Healthcare Research and Quality but the National Academy of Sciences felt it was appropriate to share its findings with the rest of us. They believe there is moderate evidence to support being active as something that we can do to stave off cognitive dysfunction. They are not asking us to become marathon runners or tri-athletes but just get up and keep moving for ninety minutes a day. There is additionally fairly good evidence that controlling our blood pressure especially during mid-life will help your chances of avoiding dementia. The most controversial area was whether cognitive training with brain teasers, puzzles, learning a new language is of value. I will advise my patients that if they can find a cognitive training activity they enjoy then they should pursue it because it certainly will not hurt. The paper did not address issues which we know are important to control such as avoiding smoking or excessive alcohol of narcotic intake.

At the same time that the National Academy of Sciences was offering a small ray of hope we see articles on artificially sweetened drinks being associated with increased risk of dementia. Add common medications like proton pump inhibitors (Nexium, Protonix, and Pepcid) and overactive bladder medicines to the list of drugs that can increase your risk of dementia. We also can add the cholesterol lowering medications called statins to the list of drugs that can increase your risk of dementia but primarily in inactive individuals.

The information is non-stop and it is never ending. A few years ago I attended a lecture by the head of one of the Harvard Medical School’s Geriatric Programs. The speaker was a family practitioner in her fifties or sixties who stressed the importance of getting plenty of exercise, eating in moderation, cultivating and maintaining relationships with friends, avoiding smoking, controlling your blood pressure and blood sugar and playing “ brain games” if you enjoyed them . It seems that with the latest publication of the National Academies of Sciences, Engineering and Medicine, not much has changed since then.

Telemedicine and Acute Stroke Treatment

My community hospital is holding its quarterly physician staff meeting and one of the items on the agenda will be a bylaw change which will permit outside physicians, not credentialed or vetted by our hospital credentials committee, to perform video consults on patients within our hospital. Hospital administration is pushing this bylaw change, and since there has been a quiet coup which has transferred medical staff power from the community’s practicing physicians to the hospital employed and paid physicians, it is a foregone conclusion that it will easily pass.

The bylaw change is being requested because the hospital would like to continue to reap the benefits of being an ischemic stroke comprehensive treatment center and offering the health benefits to the community despite not being able to meet the criteria. If a patient presents to the emergency department within four hours of developing ischemic stroke symptoms they must be offered the administration of a “clot busting “drug Alteplase (t-pa). The patient must not have any bleeding tendencies and no evidence of active bleeding or a mass or tumor on head CT scan and must be examined by a neurologist within 45 minutes of arrival.

The problem is that most community based neurologists with outpatient office practices and hospital staff privileges cannot and will not drop everything they are doing and run to the emergency department to evaluate a new patient each time a stroke protocol patient arrives. When given an ultimatum by the hospital administration, that they must take call and be available within 45 minutes, our community neurologists en masse relinquished their hospital privileges.

The hospital countered by bringing in several research oriented academic neurologists and neurosurgeons to man the beautiful new Neuroscience Institute and provide coverage of the ED for the stroke protocol. Few if any of these physicians were able to develop and maintain a practice within the community and they have since left. The Emergency Department is staffed by employed board certified emergency physicians who are well qualified to diagnose an ischemic stroke and administer t-pa. They refuse to do so citing the liability of a poor outcome as the reason. Despite data indicating the benefits of t-pa administration in these situations, the 6 out of 100 chances of a bleed in the brain plus the 1 in 6 chance of death is enough to deter their participation.

You would think that since the hospital hires these physicians the logical choice would be to fire them and hire a group that will provide the state of the art care in a timely fashion. This has not occurred. You would think that the state legislature would grant the ED physicians sovereign immunity from medical malpractice suits if the patient meets the criteria for the ischemic stroke protocol and the patient is given appropriate informed consent for the procedure but this common sense legislation has not been developed or passed.

The hospital has chosen a different pathway. They are opting to hire neurologists from a university medical center who will provide video consults on ischemic stroke patients from an offsite location. Robots will actually examine the patient and televise the data back to the telemedicine center after an emergency department physician performs a brief initial evaluation. The neurologist off site will then provide the needed neurology consult to proceed with the injection of the clot buster.

I suspect the mechanism will work like this. A patient or family member will call EMS via 911 and be taken to the Emergency Department. A triage nurse will ask all the questions to qualify the patient for the t-pa protocol; a robot will examine the patient and transmit via TV the data to an offsite neurologist while an ER physician does an exam. A CT scan of the head and brain will be performed. If no bleed is discovered or tumor or mass that could bleed, t-pa will be administered by the pharmacy and nursing staff. Further intervention by an interventional radiologist and or neurosurgeon may then occur.

At no point in this protocol does it call for the patient’s primary care doctor or cardiologist or usual neurologist to be called. We will be called once the procedure is complete because neither the ER physician or the neurosurgeon or the interventional radiologist will want to admit the patient to neurology ICU. While our surgical ICU and Medical ICU/CCU are covered 24 hours per day by an outsourced hired intensivist group, the neuro ICU does not have that type of coverage.

I can hear it now, my phone ringing and upon picking it up I hear the voice of a clerk in the Emergency Department, “Hello Dr Reznick, Dr. Whateverhisorhername wishes to speak to you about patient Just Had A Stroke.” I get put on hold for five minutes and then in a flat nasal voice, “Hello Steve your patient came in earlier by EMS with symptoms of an acute ischemic stroke. They met the t-pa ischemic stroke criteria and were treated. Unfortunately, they had a major hemispheric bleed with mass effect and edema and are now unresponsive and intubated on a ventilator. We need you to come in and admit him and care for him.”

I will vote in protest against this bylaw. I will lobby for recruiting neurologists who are hospital based who will actually see the patient and care for them. I will lobby for a new state law to provide sovereign immunity for ED physicians treating ischemic strokes according to the internationally recognized protocol. I will lobby for our medical and surgical residents on site and in the hospital to be permitted to administer t-pa after meeting the appropriate criteria. I will not support out of the area physicians making the final call and leaving our local physicians to deal with their results.