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.

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.

My First Day on the Job …

There has been a great deal of discussion about doctors’ in training work hours and work load. In June of 1976 I reported to the Jackson Memorial Hospital complex three days in advance of my start date for orientation. I was given a tour of the facility, filled out countless forms and waivers, received my ID badge and was ultimately sent to the Department of Medicine to receive my assignment.

Sitting in the conference room and looking at the patient assignment and ward team assignment list I found myself at the bottom of the list. “Elective Rotation – Steven Reznick MD Neurology.” While all my colleagues in the internal medicine training program left to meet their new residents and meet and learn their patients I was sent to the neurology department in the next building to perform neurology consultations. When I got to the Neurology Office the Chief Resident laughed at me. “Reznick you are on elective. There is no night call. You start in three days. Go home and enjoy your last three days of freedom. Be here at this office at 9 a.m. and we will see what if any consults we have to do.”

Three days later at 7 a.m., filled with anxiety, I arrived at the neurology office which was locked and closed. At 8 a.m. a secretary arrived, showed me where to sit and I waited. At 8:50 a.m. no one had arrived yet on the medical staff and she received a phone call. “Dr. Reznick that call was from your chief resident in Internal Medicine. He needs to see you now in his office.” I asked directions on how to get there and off I went.

The Chief Resident had just completed his three years in internal medicine and was now entering an administrative and research year. He greeted me with, “Reznick I am not sure how you managed to be so unlucky but I have to reassign you from elective to Ward Team III on South Wing 8. You have eighteen patients on your service and you do not have the luxury of three days to learn them. By the way, here is the team pager and you are on call today and tonight.” “How did I get so lucky? “ I asked. “We originally had an anesthesia resident rotating through medicine but he decided after orientation that he did not want to be a doctor so he just left.”

The Chief gave me directions to SW-8, which was at least air conditioned, and off I trudged. Upon arrival I went to the nursing station, introduced myself to the charge nurse and asked if my ward team was around. “They are not back from morning report yet but we need you in 828. The priest arrived fifteen minutes ago and they are waiting for you to terminate life supports.”

My first patient was 28 years old with widespread metastatic terminal breast cancer. After multiple seizures from brain metastases and an unsuccessful CPR attempt she was “brain dead” on a ventilator. Her family had chosen to terminate life supports and my role was to walk in, disconnect the ventilator and pronounce her dead when she stopped breathing. I walked in, introduced myself, shook hands all around and listened to the family talk about my new patient. When it was time the nurse and priest walked to the ventilator and disconnected it with me holding my hands so I did not feel like I was doing this alone. The nurse adjusted the morphine drip and the patient peacefully and calmly ceased breathing. I listened for a heartbeat, felt no pulse, saw no respirations and spoke to each family member and the priest as my pager screeched, “Call 4125 MICU for a transfer.” I found a phone and called. AC, an intern said, “Hi Steve. We are transferring a 23 year old with rhabdomyolysis and acute tubular necrosis (kidney failure) just off peritoneal dialysis with calcium of 16 out to the floor because we need a bed for a younger more salvageable patient. Can you come get him please?”

The charge nurse on SW-8 gave me directions to the MICU and it took me five minutes to walk there. Out in the hallway was a large stretcher with an even larger gentleman on it with two IV lines running almost wide open and three volumes of charts each larger than the Encyclopedia Britannica. There were no transporters or orderlies to move the patients at this large public hospital so I was left to push the bed along the course I had just walked to get back to SW-8. We walked through non air conditioned East Wing which was considerably more difficult pushing a stretcher than on the original trip.

On the way I introduced myself to Frank, my new patient and began to take a history. Poor Frank was a furniture mover who developed a fever and chills while moving a piano up some stairs and, when he got home and went to bed, had terrible muscle pain. He was too weak to get up so he called 911 and was brought to the hospital three months earlier. For some reason his muscles had decomposed due to the infection, heat and bad luck. The dissolving muscle enzymes were like molasses as they passed through the filtration of the kidneys clogging them up and sending him into acute and life threatening kidney failure. He had survived dialysis and infection and was now being bumped out of the unit for a “younger more salvageable patient.”

When I got back to SW-8 and placed him on his bed I sat down with his chart, overwhelmed and considered using the same option that the anesthesia resident had exercised. I was reading and crying when I felt a hand on my shoulder, looked up and my new resident introduced himself. “You have had a tough morning. Let’s go to the blackboard and talk about hypercalcemia and how to treat it. I bet you know far more than you think you do. I have you covered, don’t worry.”

We were almost through his chalk talk and were about to examine the patient when the beeper screeched again. “Please call 4225, the ER. We have a GI bleeder and he is your admission if he doesn’t arrest before you get here.” John, my resident, jumped up and screamed, “Follow me.” He was running full speed, down the stairs and towards the ER. It was a ½ mile run if not more. When we arrived, sweaty and panting for breath we noticed a jaundiced man surrounded by doctors and nurses with blood spurting upwards from his mouth like an oil well that had just been opened wide. John pushed them aside, felt for a pulse and said to me, “Start CPR.” I got up on the stretcher and started compressions with each compression producing a geyser of blood out of his mouth and on to my white coat and clothes. There were no goggles. There was no barrier protection. “Stop compressions, “he ordered. “There is no pulse or blood pressure, let’s call it.” “Time of death 9:55 a.m.” John directed me to the chart where I wrote a brief note, called the next of kin and informed them and then changed into clean scrubs. “We have about an hour or two now before another admission so let’s go back to the floor, finish up with your surviving patient and get to learn the others.”

At 7 p.m., having rounded with me on all my new patients, John asked me if I had eaten all day and did I live alone. I told him I had not eaten anything since coffee in the neurology office and I was married. He suggested I call home and tell my wife that I wasn’t coming home that night. “Let’s get you to the cafeteria, get you some nourishment and let me introduce you to the resident covering you and Dr Homer tonight.” Since I was not assigned to patient care at orientation, I had not been issued meal tickets. I had about five dollars in my wallet so John gave me some of his meal tickets for a meal. John was a saint. My covering resident was his equal. “Pat” called me a “thoroughbred stallion who needed to be brought along slowly.” She gave me her pager number and told me to call her if I got an admission or if I had a patient care issue. The two other interns on our team were excellent. They made me a summary of their patients and wandered home at about 8 p.m.

The time from 8 p.m. until 3 a.m. was a vast blur. There was an admission of an elderly gentleman with pneumonia. It required drawing all his bloods, labeling the tubes and carrying them to the lab. I had to wheel him to x-ray for a chest x-ray (there were no CT Scans yet), obtain a sputum specimen and gram stain it for Tuberculosis. There were the three blood cultures to draw, starting the IV line and antibiotics and of course writing the admission note and orders and dictating them. There were countless calls from nurses about infiltrated IV lines to be restarted, headaches, fevers requiring me to show up and draw blood cultures, family members calling to discuss their loved ones status.

At 2:30 a.m. I wandered into the ER because I was up for the next admission. “Pat” looked at me and said, “Go into the lounge, lie down and take a nap. Give me your pager. If anything comes up I will wake you. You need a nap.” That simple act of kindness and consideration and a 30 minute nap was like a shot of Café Cubano and adrenaline and, when 7 a.m. work rounds began with my ward team back on site with my resident John, I was relatively fresh to face a new day. I passed the pager to Phil, the other intern, as he asked me, “How did it go?” Somehow I mustered up a “No sweat especially with resident coverage from John and Pat.  John is covering you tonight so I expect you will be fine!”

We got very little sleep during my internship (PGY1) and residency training. We worked 100 plus hours weekly. The patients we saw were mostly severely ill and complex. We did all the lab work ourselves in the ER house staff lab. We started all the IV’s, drew all the bloods, and transported the patients ourselves. The work was physical, demanding, cerebral, emotional and exhausting. Every new patient was seen by an ER physician and attending, an intern, a medical student, a covering resident.

They were reassessed at 7 a.m. on work rounds with your resident and ward team plus often the chief resident. At 9 a.m. you presented the new admissions to a faculty member and the entire residency class at morning report. At 10 a.m. you presented the case to your team attending physician on attending physician rounds. This faculty member reviewed the case, examined the patients and wrote a note documenting agreement with the care plan. At noon your resident presented the case to the Chief of Staff at Chief of Staff Rounds. By 1:00 p.m. the problems and decision making had been reviewed and discussed by six or seven physicians. Sleep was not an issue in decision making because we had so many immediate layers of patient decision making reviews.

Our overworked supervising residents for the most part were caring and helped us out if we were exhausted or in over our heads. Our chief residents were available around the clock if we needed extra help.

I do not want today’s doctors to have to work as hard and perform the menial tasks that I was required to do for any reason let alone because I went through it and survived. I do not believe that the layers of supervision and questioning of your decisions allows for sleep deprived errors and mistakes if everyone is doing their job appropriately. I do feel fortunate that I learned to stain specimens and look at them under the microscope and run electrolytes on flame photometers and learn how to set up cultures of blood and urine on culture plates then read them. It taught me the time involved and the limitations of the test plus the margins for error.

I do believe the high volume of severely ill individuals I cared for broke me down and made me a dehumanized efficient machine. I was fortunate that caring faculty built me up and reminded me why I went into this profession to begin with.

Last week a prospective new patient came by to meet me at my office and see if he wanted to join my practice. During the discussion he lifted his shirt and showed me some scars on his abdomen. “You don’t remember me? You gave me those scars inserting catheters to do peritoneal dialysis on me on SW-8 on your first month as a doctor. I remember how frightened you were that you would hurt me or kill me. I was suffering from kidney failure and high calcium after my muscles broke down from an infection. You treated me for six weeks after I left the ICU and transferred me to an acute rehabilitation hospital where I learned to walk again. I live in this area now and I found you on line and want to be your patient again.”

It’s incredible how life always seems to come around full circle!