Dying From Dirt

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Photo: A clean sink. Flickr, Creative Commons. Slash mark superimposed on photo.

Photo: A clean sink. Flickr, Creative Commons. Slash mark superimposed on photo.

Many years ago, when my father was working his way through psychiatric diagnoses, my mother-in-law, whom I’ll call “J,” said, “If I ever get like that, take me out back and shoot me.”

She was kidding, of course, but not really. And now the time has come when she’s no longer making fully rational decisions. Yet the situation is confusing.

“J” is 86 years old. She was a 2-pack-a-day smoker, since her mid-twenties, until a mild heart attack scared her a few years ago and she finally quit. But the damage had been done. COPD. Heart failure. Spinal stenosis. Atherosclerosis. Peripheral vascular disease. Hypertension. Most of the conditions are controllable with meds, and when asked at medical exams about her illnesses, she claims not to have any. About a year ago she started oxygen supplementation at night. Soon she was reading again, aware of the news, and the repetitions of the stories about how bratty my husband was as a boy noticeably declined.

Now she needs oxygen 24/7. I’d been saying this for many months, being the person who schleps her to most medical appointments. I’d have to ask the cardiologist to check her oxygen saturation – he a competent doc and seemingly nice man who nonetheless harbors an ill-disguised attitude that someone with 2 X chromosomes (me) couldn’t possibly know anything. Her pulse ox would be ok after taking a few steps in the hallway after having sat in the waiting room for 30 minutes. But lately I’ve noticed she can’t go 4 steps without becoming completely winded.

In recent weeks, as the exhaustion and muscle pain worsened, I tried contacting her primary care physician several times, and was ignored. I had to actually go to the doctor’s office to read the echocardiogram myself because the nurse could not interpret it. Well, last week, the PCP finally examined J at the assisted living facility and called me, alarmed. She related everything I’d been trying to tell her for years.

J has selective hearing in a medical setting. She goes to a doctor’s appointment with a set phrase – “I’m in good health,” for example – and manipulates the conversation until the doc utters something that seems to agree. At her first appointment with a nephrologist about 18 months ago, however, the young doctor would not be cowed. He explained half a dozen ways that she was in kidney failure. But back at assisted living, she announced to the gang, “The doc gave me a clean bill of health!

And so a few days ago, after the PCP’s found a pulse ox of 88 and ordered assisted bathing at least thrice weekly (I’ll get to that in a minute), we stopped in for a visit. When my husband brought up the oxygen issue, J went crazy.

“They decided it was a mistake, I don’t need it.”

Who is ‘they?’

“The nurse.”

I doubted that the nurse at the assisted living facility was going to counter a doctor’s order for oxygen. But that’s the least of the problems.

J may die of being dirty.

When the choking haze of cigarette smoke receded in the aftermath of the heart attack that forced the quitting, when J was still living alone, a distinctive odor emerged. She wasn’t washing. Or wiping. Today her unit at the assisted living facility smells like a large mammal died and decayed in her living room. Recurrent fungal infections ravage the folds of flesh that she can’t reach. People have commented on the pervasive smell since she arrived two years ago, but nothing was ever done, I think because she is in financial control. Last week the PCP, after instructing us to insist on assisted bathing since we pay the bills, was shocked to learn this was not the case.

If J does not go on constant supplemental oxygen and get herself cleaned up on a regular basis to control the fungal and other infections, the PCP told me, she wouldn’t last a year. She didn’t mean last a year until she was moved to a nursing home. She meant last a year, period.

Like the healthy kidney conclusion, J denies both problems. Her inability to smell her own stink is yet another consequence of long-term smoking, her respiratory cilia having long since vanished. And the lack of oxygen may be impairing her thinking. If J is refusing the round-the-clock oxygen, she will certainly refuse someone cleaning the extended microbiome from her various nooks and crannies on a regular basis, which she will have to pay for.

So what do we do?

When my father was close to death from paranoid depression, my sister and I, not being truly informed, refused electroconvulsive treatment. An ethics committee at the medical center intervened and overruled us – and it gave him two more years. Can a PCP do the insisting for us in the present situation?

I’d support J’s decision to forego something horribly invasive or painful – chemo, coronary bypass, or dialysis. But supplemental oxygen and bathing? I understand that these interventions represent a loss of control, and perhaps an acknowledgment that she has been in deep denial of medical matters. But if we do not, somehow, insist, in an attempt to honor her autonomy, she may die of too much dirt and too little oxygen.

Advice welcome!

This post was written by an anonymous contributor to PatientPOV.org.

 

 

 

 

 

 

Posted in aging | Tagged , , , | 8 Comments

5 Fun Facts About the New York Health Insurance Marketplace AKA The New York State of Health

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776px-Map_of_New_York_NAI had the pleasure of hearing Elizabeth R. Benjamin, MSPH, JD, Vice President, Health Initiatives, Community Service Society, of New York, at a presentation she gave on the new insurance marketplace for the New York Chapter of the Association of Healthcare Journalists tonight.

Sorting through the changes is daunting, but I thought 5 facts she discussed show what might set New York State apart from many other states:

  1. Thus far, New York State has enrolled approximately one-third of the nation’s enrollees. According to Benjamin, 100,881 New Yorkers have enrolled of approximately 300,000 across the United States.
  2. New Yorkers have been accustomed to choice in health coverage, but on one issue, out of network coverage, none is allowed. Advocates are pressing to change that.
  3. As the marketplace launches, premiums in New York State have dropped by 53%.
  4. New York State has a more streamlined approach to getting financial help than many other states. If you are eligible for financial help, the marketplace will determine your eligibility early in the enrollment process. You do not need to apply for financial help separately.
  5. As of Dec. 12, two carriers (United and Empire) had not invoiced people who signed up, but both promise to bill people next week. Given that Dec. 31 is the deadline for paying your invoice, it’s making lots of people jumpy.

Additional Resources

If you are still looking to enroll, many resources are available, including navigators to help you select your plan. Check out these resources:

New York State of Health: www.nystateofhealth.ny.gov

Community Health Advocates: www.communityhealthadvocates.org

            For enrollment help, call 1-888-614-5400  tollfree.

Email: enroll@cssmy.org

Small Business Assistance Program: www.sbapny.org

Health Care for All New York: www.hcfany.org

You can also keep informed about the law, timetable, and changes here.

Find coverage: www.healthcare.gov

It’s been a bumpy ride. Do you think the marketplace will work in New York? Have your say in the comments below.

Posted in Healthcare reform, Obamacare | Tagged , , , , | 1 Comment

When You Read that Radiology Report, Are You Worried, Getting Unnecessarily Primed for More Consults and Tests?

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Diana Miglioretti, PhD, the lead researcher, standing next to a CT scanner. Photo credit: UC Davis Health System, Sacramento, CA.

Diana Miglioretti, PhD, standing next to a CT scanner. Photo credit: UC Davis Health System, Sacramento, CA.

A few years ago, I watched a relative poring over her father’s chest x-ray report hanging on every word. He was 89. Everything sounded scary and worthy of worry.  It’s bad enough when patients go for these tests, the machines alone are huge and enveloping. So you are almost set up to worry as soon as you have the study done.

There’s plenty wrong with radiology reports that can push you to fear the worst. According to Dushyant V. Sahanyi, MD, associate professor of radiology at Harvard Medical School, in fact, patients are scared far more than they should be in many cases. Dr. Sahani told Patient POV about a high proportion of patients coming to him for a second opinion who thought they had terminal diseases, based on their initial radiology reports. It turned out that all but one had findings of no consequence to their health. Dr. Sahani said:

“These patients thought that they were going to die because the language used in the reports was so frightening. When I reviewed and discussed their reports with them, many started to cry because they said that they never expected to hear such good news.” - Dushanyi V. Sahani, MD, Director of CT Imaging, and radiologist in the Division of Abdominal Imaging and Intervention at Massachusetts General Hospital in Boston.

Radiology Reports Use Misleading Language

One problem is that radiology reports are filled with annotations that are loaded and inconsequential to patients’ health and wellbeing. Reports flag all sorts of things that are nothing more than:

  • Misleading medical jargon;
  • A part of the normal aging process;
  • Incidental findings that mean nothing is wrong;
  • Benign findings –(having little or no detrimental effect);
  • Indeterminate lesions.

The terminology varies from radiology department to department, explained Dr. Sahani, but going forward, “radiologists need to work at more clear communication in these reports.” It’s not just patients that are baffled by the reports; sometimes referring physicians can’t make heads or tails of them or they don’t address the precise reason why the doctor ordered the study or amplify the most clinically significant findings. Instead, the important findings are buried in the reports.

Introducing Reform

Dr. Sahani and many other radiologists are working on changing the way reports are written. The benefits are clear: patients won’t be unnecessarily scared to death a lot of the time and won’t begin a cascade of unnecessary consults and more tests. Referring doctors would also benefit: they could get information they need that is not mired in radiology lingo of no consequence.

Some ideas that Dr. Sahani and other radiologists suggest include:

  1. Putting the most important finding clinically at the top of the report in plain English.
  2. If there is something urgent in the report –even not having anything to do with why the doctor ordered it—put it at the front of the report.
  3. Stop inserting excess information that is not clinically relevant.  That runs the gamut of amplifying findings related to aging, including repetitious ways of describing the same finding, or factoids only of interest for a radiology textbook.
  4. If additional imaging could help uncover what is wrong, specify why so that the referring doctor can explain it to the patient. Without it, it looks like the radiologist is looking to do an unnecessary procedure.
  5. If something is especially complex, radiologists should call or email the referring physician.
  6. Radiologists should also consider leaving a contact number for further questions.

There’s a silver lining in radiologists opening up about misleading radiology reports. Radiologists like Dr. Sahani and many others across the country are spearheading campaigns for more standardized radiology reports and more clear communication. It may be difficult to achieve consensus on what belongs in a report or what should be excluded, but it’s a good first step.

Pathologizing Not Unique to Radiology

Meanwhile, patients reading radiology reports should recognize that the reports may not be as alarming as they might seem on first glance.  We are a long ways away from not pathologizing every finding in medicine. Patients need to maintain a high level of  skepticism.

The same is often true for reading urine and blood results. Something may be outside the boundaries of “normal” or the “reference range,” but for a specific patient, it may be of little consequence.

 

 

 

 

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Concussions in School Sports: Is Culture Change Possible?

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About a month ago, I stumbled across a news story in the Chicago Tribune about Drew Williams, a Lane Tech High School football player collapsing unexpectedly on the football field during a game. Ever since, he has been in a coma. Drew had no apparent collision during the game and that shocked and troubled bystanders. After the incident, a father of another boy on the team told his son that it was just fine if he didn’t want to play in the last few games this year.

Drew was taken away on a stretcher and brought to the hospital by ambulance. He was hospitalized until this week, when a transfer to a rehabilitation facility was authorized. However, shortly after his transfer, he suffered a setback and was rushed to a hospital because of a serious infection. His family asks for prayers and hopes to raise funds for him to pull through on a Facebook page dedicated to “this marathon we call recovery.

Could Drew’s injury have been prevented?  I don’t know. I certainly don’t feel comfortable bothering his family for an interview now, in what is clearly a very difficult time. But I read the story shortly after I attended a meeting on concussion prevention in school sports.  I am glad that concussion outcomes and prevention are getting the attention that they deserve.

For boys, the most worrisome sports are football, ice hockey, lacrosse, wrestling, and soccer. For girls, soccer, lacrosse, and basketball account for the most head injuries.

Recent reports of suicide, traumatic brain encephalopathy, and violence in NFL players and other athletes are troubling. In the report commissioned by the Institute of Medicine and National Research Council released Oct. 30, the authors call attention to “changing the culture.” The authors write:

“Too many times the committee read or heard first-person accounts of young athletes being encouraged by coaches or peers to “play through it.” This attitude is an insidious influence that can cause athletes to feel that they should jeopardize their own individual health as a sign of commitment to their teams.”-     p.6, Sports-Related Concussions in Youth: Improving the Science, Changing the Culture, National Academy of Sciences, Oct. 2013, prepublication copy.

Why is There Not More of a Public Outcry?

When you take a look at reports like the Institute of Medicine/National Research Council and recent peer-reviewed publications on outcomes of concussion, a huge knowledge gap is evident, but what is known is not comforting. Some of the more disconcerting issues to think about are as follows:

  1. Head injuries are invisible to observers beyond perhaps watching initial impact. Brain swelling and bleeding won’t be obvious without medical evaluations.  Problems with memory and processing speed may only be evident if objective testing is done.
  2. Research into the effects on the brain after concussions in youth, and differences between boys and girls, and different ages have only recently begun. So play continues with incomplete knowledge.
  3. After one concussion, athletes may be at greater risk for more severe concussions and take longer to recover. Not recovering from a concussion may be a key risk factor for another concussion, and increased severity of subsequent concussions.
  4. No sports figure has emerged yet that could serve as a role model for safety in sports. We have had suicides and violence in NFL active and retired players. This has propelled a research infrastructure, legislative changes, and some outreach.
  5. Only recently have we begun to track the course of recovery. Historically, questions about malingering unfairly stigmatized kids who were not recovering.
  6. Information on the race, ethnic background, or socioeconomic status of youth who sustain sports related concussions is not reported in studies, so we cannot determine if disparities exist. However, given that about 2/3 of NFL players are African-Americans and football injuries are the leading cause of head injuries for males, one wonders if a similar proportion of African-American youth is at increased risk of concussions.

There are some positive signs. In a subsequent post, I will point to legislative changes, research, and educational programs that could help reduce concussions.

 

 

 

 

 

 

 

 

 

 

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Back Pain Treatment Trends Worth Reversing

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It may just be the American way –pull out all the stops and try anything or everything at great expense when it comes to medical care.

Today’s post takes up how well the United States is doing at providing back pain care in accordance with evidence-based clinical practice guidelines for back pain (including neck pain). In original research and a commentary published online July 29, 2013 in JAMA Internal Medicine, John N. Mafi, MD, and coauthors from Beth Israel Deaconess Medical Center and Harvard Medical School, in Boston, MA, point out troubling trends in back pain care using nationally representative data from the Centers for Disease Control and Prevention’s National Ambulatory Care Survey and the National Hospital Ambulatory Care Survey.

Back pain is common, with surveys showing that 65% to 80% of Americans will report back pain at some point in their lifetime. So understanding what’s going on and managing it with the best science sounds good for patients. Back pain is a loaded category for sure: it involves how well patients can tolerate pain, patience because back pain is often temporary, yet it can be a springboard for all sorts of referrals. There are some relatively inexpensive ways to manage back pain that get a grip on back pain, but the study discussed here suggests that people want to throw everything at it and that the care people are getting is moving afield from science-based guidelines.

Prescribing Patterns

oxycontinBetween 1999 and 2010, opioid use for back pain climbed substantially from 19.3% to 29.1%, while recommended nonsteroidal anti-inflammatory drugs (NSAIDs: e.g. ibuprofen) and acetaminophen have declined by nearly half, from 36.9% to 24.5%.  The latter two drug categories are recommended as first-line for patients with back pain. Additionally, doctors in the south and west prescribed narcotic medications about 1.5 times more frequently than doctors nationally.

Not everyone gets opioids prescribed. The odds that women, black, Hispanic, and other racial/ethnic groups, and the uninsured were prescribed opioids was significantly lower. Commenting on this disparity, Richard Deyo, MD, MPH, Kaiser Permanent Professor of Evidence-Based Family Medicine, Oregon Health Sciences University, Portland, OR, said: “I think this is a situation where good insurance – and greater affluence – make overuse more likely. This may be a case where underinsurance has a protective effect!”

Imaging

MRI machine

MRI machine

Subgroup analyses revealed that neurologists and orthopedic surgeons had a far greater odds of ordering CT and MRI: more than 3.5 times higher than primary care doctors. MRI scans and CT scans rose between 1999-2000, at 7.3% to 11.3%, in 2009-2010.

Referrals

Physical therapy referrals remained constant over the ten-year period, but referrals to other doctors, especially neurologists and orthopedists, doubled by 6.8% in the first year of data collection to 14.0% in 2009-2010.

One Limitation: No Surgery Data

 The data are limited in that this data set cannot be used to see whether or not people got surgery.  However, lots of previous research suggests that with the cascade of advanced imaging and physician referrals, people are getting surgery more frequently.

What About Patients?

 In this study, trends in management of back pain suggest care is moving away from science-based medicine. Many of us have endured back pain that feels acute or chronic. Some of us know people who have had back surgery, seen lots of doctors, and gotten imaging studies. As I write this post, the news is calling attention to premiums perhaps not being that high as predicted with Obamacare. But you have to wonder: if these patterns of overuse to no good end for patients persist, the costs are going to get thrown back to patients. I’ve said this before, but I think we are at a standstill. We need to move beyond documenting overuse and inappropriate use and come up with ways to get doctors and patients on board with what works and does not.

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Cardiovascular Care and the Bush Effect

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Pres Bush at NIH

It’s too soon to tell whether former President George W. Bush’s stent to open his coronary artery will change how Americans receive cardiovascular care, but I certainly have my worries. If the argument to aggressively search for cardiac disease in asymptomatic people wins out, I see my healthcare premiums rising precipitously and continuing in that direction. It’s not just the premiums either, but putting healthy people into this perennial-patient or at-risk status for no good reason.

I don’t want to live in a world where we speak of how elevated each of our risk status is for cardiovascular disease, a stroke, or heart attack, as if it is a badge of courage. I learned recently that I have only a 4% risk of having a heart attack or stroke in the next ten years, apparently strong enough for my primary care physician to recommend a statin to lower my risk even further.

A month ago, I went for a routine physical at my primary care physician’s office. I got recommended immunizations, but there were aspects of the visit that troubled me. Once you are in a gown sitting at the exam table, you are fair game for consenting to a procedure right there, on the spot. How stupid I was not to pull out my smartphone to check whether a test was warranted. My doctor had moved from an academic medical center to open a new group practice.

Cardiovascular Testing Flourishing

I got hornswoggled into a carotid ultrasound test. The test evaluates blockages in your neck. What led to this test was my admission after persistent questioning (I am really well) that I very occasionally feel dizzy. Suddenly, the specter of a looming stroke was in the cards, perhaps a blockage in my neck. My blood pressure was 120/80 in both arms. When I asked the technician performing the test why it was being done, she said: “to prevent a stroke.” Now who would want to have a disabling stroke? It was a compelling argument on the surface.

Other contributing factors that were too daunting to address was the fact that a cardiologist sat in the office and owned the equipment. Who needs a fight with my doctor over whether the test is warranted and might be motivated by a conflict of interest? At another physician practice, on a rainy day, I once was offered a stress EKG, because: “He’s got the time. He had some cancellations because of the rain today.” The rationale: it was a few months after my mother died. I had occasional pounding in my chest.

Had I pulled out my smartphone and looked at the American Board of Internal Medicine Foundation Choosing Wisely site or a handful of other sites either time, I would have immediately learned that a carotid ultrasound test or stress EKG was unwarranted. I recommend readers bookmark this site and challenge their doctors before undergoing tests like these. It is a valuable reference. I should have known better. (Note: at press time, the link on the website was broken. It will be inserted as soon as ABIM Foundation fixes it.)

With my insurance, I only got stuck with a relatively small copay, but what would happen if everyone who walked in the door was seen unwittingly as a candidate for this procedure, stress EKGs, and more? Make no mistake about it, it’s happening. You tolerate it, fellow Americans, you are going to have to pay for it. Don’t be surprised if your premiums go up and if healthcare costs wipe you out. I may not pay for this kind of test this year, but it won’t be long before the economists make sure Americans fork out for these tests.

Oddly enough, when I returned home, in my mailbox, I found a glossy, oversize postcard from a teaching hospital touting its cardiovascular disease prevention program. They are popping up everywhere, offering a potpourri of risk assessment for heart attacks, strokes, and vascular disease, risk factor identification, treatment programs to reduce risk factors, secondary prevention, and screening before starting sports and exercise programs.

I don’t think that Bush was needed to propel overuse of cardiovascular procedures further over the top. It has been well on its way, but Bush’s stent underscores the trend. In this blog, in many posts, I have pointed to the numerous ways overuse is hazardous for your health, financial wellbeing, and more. It will be up to those concerned with overuse to devise new strategies to stop this train. Right now, it seems unstoppable.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Posted in cardiovascular care | Tagged , , , , , , | 3 Comments

How Safe are Electronic Cigarettes? Not Everyone Agrees.

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Ads for Electronic Cigarettes are EverywhereMy friend lit up her electronic cigarette during intermission when we were on line for a bathroom at a Broadway theater. People on the line looked at her disapprovingly. She responded quickly: “I am not smoking. It’s only water vapor.” That’s the argument that the e-cigarette industry makes, and it is clearly one that my friend wants to believe. Her response put a stop to any questions about second-hand smoke. Nobody else said anything. Maybe nobody wanted an argument on a night out for theater or maybe people knew too little to comment confidently. She waited for a bathroom stall and continued smoking.

While questions about electronic cigarettes stayed below the surface in the ladies room, they are hotly debated in the world of tobacco control and public health. There are concerns about the exact benefits and potential harms of electronic cigarettes, second hand smoke, and air quality. Proponents see e-cigarettes as a safer alternative to traditional cigarettes, but skeptics question how safe they really are, both for users and people exposed to them as second-hand smoke. So far, they have been manufactured and distributed without oversight, data, or proof that they are a bridge to quitting more toxic cigarettes. Also, many experts question the industry line that just water vapor is released when users light up.

Product Regulation Considered

In Lancet Respiratory Medicine, two commentaries put forth opposing views on the question of regulating electronic cigarettes as medical devices. In one, Nathan K. Cobb, MD, and Caroline O. Cobb, from the Department of Pulmonary and Critical Care Medicine, Georgetown University Medical Center, Washington, DC,  warn: “Without oversight or consumer safety regulations, the manufacturers of ENDS produce products that are more widely available, much cheaper, and might contain more nicotine and contaminants than competitor products manufactured by pharmaceutical companies.”

Cobb and Cobb want regulation. They frame the issue this way: “The question should be what regulatory system will get safe and effective refined nicotine products into the hands of more smokers and promote elimination of the most lethal combusted products?”

In the second commentary, Peter Hajek, Director of the Tobacco Dependence Research Unit at the Wolfson Institute of Preventive Medicine, Queen Mary University of London, UK, and colleagues, argue that regulation will stifle innovation, the development of better healthier electronic cigarette designs, and hinder  competition of ecigarettes against more toxic traditional cigarettes.

Product regulation is only one part of the story. It is what the Food and Drug Administration can address. Local governments will have to decide where people can use e-cigarettes, and whether air quality statutes should issue standards.

E-Cigarette Use Patterns

I asked Stanton Glantz, PhD, Professor of Medicine at the Center for Tobacco Control, University of California San Francisco, and leading tobacco control expert, to comment on the Lancet Respiratory Diseases papers, and address concerns about the use and proliferation of e-cigarettes.

Q: What did you think about the opinions on e-cigarette regulation in Lancet Respiratory Diseases?

A (Glantz): The pieces were focused on e-cigarettes as products. They did not address what effect e-cigarettes have on use patterns. We’ve found very high levels of dual use [traditional cigarettes along with e-cigarette use]. Very few people have switched away from cigarettes or managed to use them as a bridge to eventually go off cigarettes. While many people believe e-cigarettes helped them quit smoking, neither of the available population-level studies showed such an effect.  One showed e-cigarette users and nonusers quitting conventional cigarettes at the same rates, the other showed e-cigarette users being less successful at quitting.

Q: Where do the authors stand on harm reduction and addiction?

A (Glantz): The articles reflect the polarization in the public health and tobacco control communities. The optimists – the harm reduction people (in this instance Hajek et al.)– essentially believe that electronic cigarettes are much less dangerous than traditional cigarettes and so their use should be encouraged. The pessimists (Cobb and Cobb) see electronic cigarettes as an addictive drug, that without regulation, are not going to market in a way that will disrupt the primary profit stream of cigarettes, and so could end up just keeping people smoking conventional cigarettes.

There’s an assumption among the harm reduction people that if you could snap your fingers and get every smoker to switch to e-cigarettes, you’d be ahead. One problem is that you can’t do that. While the industry uses social media and the internet to present e-cigarettes as a miracle way to quit, as noted above, no independent studies show that e-cigarettes actually help people quit. They may even discourage quitting.

Q: In what camp do you put yourself?

A (Glantz): I am a realist who is driven by data. I started out agnostic on e-cigarettes. While there is not a lot of information available now, what is there is pointing to dual use and ecigarettes impeding quitting cigarettes. All the big cigarette companies are now getting into this market. They are not going to market those products in a way that jeopardizes the cigarette market.

Q: Do you agree with the harm reduction people that e-cigarettes are a safer alternative for smokers?

A (Glantz): If smokers switched entirely from conventional cigarettes to e-cigarettes, no one started smoking because of e-cigarettes, and e-cigarettes did not discourage quitting, smokers would be better off.

Contrary to marketing claims, e-cigarettes do not deliver pure nicotine and harmless water vapor. In 1986, California passed a ballot initiative known as Proposition 65, which was intended by its authors to protect California citizens and the State’s drinking water sources from chemicals known to cause cancer, birth defects, or other reproductive harm, and to inform citizens about exposures to such chemicals. Annually, the Governor must publish a list of chemicals known to the state to cause cancer or reproductive toxicity. Ten compounds that are on the Proposition 65 list have been identified in mainstream (MS) or secondhand (sidestream/SS) e-cigarette vapor (See table).

Ten Compounds Found in E-cigarette Mainstream* or Secondhand Smoke**, Also on California’s Proposition 65 List

* Acetaldehyde (MS)
* Benzene (SS)
* Cadmium (MS)
* Formaldehyde (MS, SS)
* Isoprene (SS)
* Lead (MS)
* Nickel (MS)
* Nicotine (MS, SS)
* N-Nitrosonicotine (MS, SS)
* Toluene (MS, SS)

*MS – mainstream smoke
** SS – secondhand smoke

Credit: Stanton Glantz, PhD, Adapted from Gonewicz ML, Knysak J, Gawron M, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control. doi:10: 1136/tobaccocontrol-2012-050859 and Schripp T, Markewitz D, Uhde E, et al. Does e-cigarette consumption cause passive vaping? Indoor Air 2013; (1):25-31.

Q: Do you think that, based on what we know, we should ban e-cigarette use in the same places that we ban cigarettes?

A (Glantz):  Yes.  Even though e-cigarettes are less polluting than conventional cigarettes, they still are putting a variety of volatile organic compounds, heavy metals, fine particles and other toxins into the air.  Regardless of the concentrations, there is no justification for reintroducing these toxins indoors after we spent 30 years getting rid of them.

Q: Do you think that any regulatory entity has taken the lead with a strong policy protecting the public’s health with e-cigarettes? What would such a policy look like?

A (Glantz): The FDA has the ability to regulate e-cigarettes as products and should do so.  The reality is, however, that meaningful regulation is probably years away because the tobacco and e-cigarette companies (that are more and more the same companies) will do everything they can to slow it down or stop it, including through the courts.

Where you can smoke e-cigarettes is a matter for local and state governments, who are already starting to act to include e-cigarettes in clean indoor air laws.

This post appeared previously on Scientific American’s guest blog. It is reproduced here in entirety. Have thoughts on this piece? Do comment here.

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The Smoking Wars: Menthol, Minors, and More Smoking Bans

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No_SmokingIn case you thought that the war against smoking was in our rear-view mirror, it’s not.  On Monday, I had a guest blog on Scientific American concerning electronic cigarettes, which provoked a lot of heat and discussion. I’ll put it up on this blog over the weekend. I learned a lot after posting and from the comments there, which were largely from electronic cigarette advocates. As comments revealed, users of electronic cigarettes claimed that they feel healthier with them, that they are not really smoking, and that substances released into the air are minimal and of no consequence to the environment.

Research on dual use and passive smoking cannot be ignored. When it comes to electronic cigarettes, it is not just the user, but the point of view of passive smokers. My bias is that electronic cigarettes should be regulated by FDA and subjected to the same environmental bans as regular cigarettes. We can’t fly blind.

The smoking wars are still ongoing.

Menthol Scientific Review by FDA

 The FDA released a scientific review on menthol this week. As a friend who reread this post before posting said to me: “I remember when I was 12 years old, menthol was really attractive to me.” FDA validates that issue. Its conclusions are concerning:

  • Menthol masks tobacco’s harshness;
  • Menthol makes it easier to become addicted, fosters greater dependence on nicotine, and increased difficulty quitting;
  • Menthol cigarettes account for about 1/3 of all cigarettes sold in the United States, but rates of use are disproportionally high among African Americans, other minority groups, teen smokers, and women;
  • Menthol use is linked to lower socio-economic status.

This could be the first step in a ban on menthol cigarettes. FDA invites public comment.

Beware Bills Targeting Minors

Interestingly, since posting, I learned that bills are cropping up, that on the face look as if they would ban electronic cigarette use in minors. Importantly, the American Cancer Society, American Lung Association,  American Heart Association, and Tobacco Free Kids oppose them.

At issue is whether passage of these bills are merely a Trojan horse that will aid in circumventing both product regulation and bans of electronic cigarettes in the same places that regular cigarettes are banned.  Earlier this month, Rhode Island’s Governor Chafee vetoed a bill that would have prohibited minors from smoking electronic cigarettes. According to an article in the Providence Journal, Chafee viewed it as an effort by the electronic cigarette industry to stave off further regulation.

Indoor Smoking Bans

New York celebrated its 10-year indoor smoking ban on Wednesday, July 24, 2013. Many U.S. cities limit indoor smoking. Research has shown that the indoor bans have been linked to improvements in public health, including fewer hospital admissions for heart attacks and lung cancer deaths. Extending these bans to electronic cigarettes is the next battleground.

 

 

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5 Wild Healthcare Stories Happening Right Now

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In my journal of “healthcare is going to hell in a handbasket” this week, I’ve got a few items that will either make you laugh or cry. Hopefully, after that, you’ll mobilize yourself to fight for equity in health care and for penalizing the crooks. Here are five absurdities in healthcare that you won’t want to miss:

1. Severe Memory Loss. That’s the explanation John Reynolds, former CEO (1997 to 2006) of the illustrious Hospital for Special Surgery, New York, NY, gave in his court appearance. He pleaded guilty to a $300K kickback scheme involving two hospital vendors and a British healthcare organization. Will “severe memory loss” be the avant garde explanation for corruption?  You have to wonder. As the New York Daily News reported, he’ll probably serve no more than 27 to 33 months, according to Federal guidelines.

According to Crains NY Business, the case was puzzling: Reynolds was one of New York City’s top-paid hospital CEOs. In his final year at the Hospital for Special Surgery, his salary was $1.3 million. When he retired, he got $1.4 million in severance.

2. “Choose Life” license plates. I didn’t know much about these until Felice Freyer, from the Providence Journal, Providence, R.I., tweeted earlier this month that the Rhode Island Legislature had authorized “Choose Life” vanity license plates. Here’s one from Texas.

It turns out, that the highly regarded Guttmacher Institute provides a nice overview of these license plates, noting that as of July 2013, 28 states have them. In what I consider a cruel irony, Guttmacher reports: “In some cases, money generated from their sale directly supports the activities of antichoice organizations or crisis pregnancy centers (CPCs), which often provide biased and medically inaccurate counseling to women seeking a pregnancy test or counseling with regard to an unintended pregnancy.” Think about it: is this constitutional or an acceptable use of state involvement? Is there some murky mix of church and state, endorsement of a political agenda? Reproductive rights groups have challenged the proliferation of these plates in some states, and successfully.

You know what I’d like to see: A “Choose Choice” vanity license plate. But I don’t have a car, and honestly, I don’t want to die because of some anti-nut. Note: since publishing this, Marilyn Mann points out in the comments below that opposing licensing plates have been approved in a handful of states. In addition, Providence Journal’s Felice J. Freyer reports that Governor Lincoln Chafee has vetoed the “Choose Life” license plates. 

3. More abortion regulation insanity (when you thought you heard it all). Here’s a new spin on state abortion-laws that are unconstitutional and outrageous. In Kansas, if you work in an abortion clinic, you cannot chaperone your kid’s class on a school trip, involve yourself in purchase of healthcare books, or in any way represent the School Board. You are drek and better stay away from school kids. The ACLU is fighting this as unconstitutional, along with the numerous other abortion-restrictive laws in Kansas. Carol Joffee does a good job here describing this section of Kansas abortion law.

4. “Obesity stigma du jour” – that’s what @stevesilberman calls this decision by the National Boy Scouts to ban obese Boy Scouts from its annual Boy Scout Jamboree.

Gee, America is the land of excess. I sure wish we’d go after corporate America more for the excesses than to take it out on those low on the food chain. How many more “blame the victim” for excesses are we going to have to see? And. as for the Boy Scouts, how many more fiascoes are they going to be involved in? Add this one to the Gay Boy Scout debacle and the organization could soon be history.

I’ll pass on the macaroons for now.

5. Looking forward to the health exchanges? Think again. This one makes me sad. This just in from today’s St. Louis Post-Dispatch: Large insurers in Missouri are opting out of health exchanges. What anybody who wants decent insurance does NOT want are health plans with absolutely zip experience in insuring large populations.

Plus earlier this year, Trudy Lieberman reported that the model health exchange in Connecticut was deemed unaffordable. Kind of makes me cringe. This is the tip of the iceberg. I am hoping it’s growing pains as Lieberman calls it. The Accountable Care Act was looking like the next big advance after Medicare. But lots of powers are out to sabotage it. Vigilance, my friends!

Do you have an absurd story about U.S. healthcare to tell? Tell me your story. You can send me an email to “patientpov” at gmail dot com. I’ll be sure to credit you.

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Stand Up and Learn the Tradeoffs
Of Using Medical Imaging for Your Kids

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MRI machine

MRI machine

My last post raised questions about the overuse of CT imaging in children, which researchers projected could prove hazardous to kids in the form of excess solid tumors at some point in the kid’s lifetime. It’s one study, but as the study shows, a growing peer-reviewed data base points towards hazards that could be avoid.

Key issues that the researchers and editorialists raised include:

  • Around the country, pediatric radiation doses are not standardized and they could be reduced substantially to improve patient safety;
  • CT hits kids with 100 to 500 times as much radiation as standard x-rays.
  • In what cases, is sending your kid for another test distracting from real care and helping them get well?
  • What questions should parents ask to determine the tradeoffs in having their kid imaged or going through any test, or not?

Of all medical imaging tests, so far, CT stands out for the most compelling projection of harm –spelled out in terms of projected excess solid tumors that could have been avoided in a child’s lifetime if careful referral and dosing protocols were in place.

“It’s very well shown that CT scans for minor head injuries are usually of no benefit,” Ricardo Quinonez, MD, Director of Research and Quality, Pediatric Hospital Medicine, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas, and Executive Chair, American Academy of Pediatrics, Section Chair of Hospital Medicine, said in an interview. “For simple abdominal pain, simply watching it is best.

Excess CT Scans Not Only Concern

Quinonez also addressed use of magnetic resonance (MR) imaging in children under age 7. “Most kids need sedation and safety is not a completely settled question, with anesthesia having negative consequences on brain function.” Quinonez questioned whether MR is being overused more and more. Even though no negative consequences from the magnets have been observed directly, there are downstream risks, potentially unnecessary surgeries.”

Another concern is the use of chest x-rays for asthma and bronchulitis. Quinonez stressed that diagnosing these problems can be done clinically, meaning hands-on physical exam of the patient. Chest x-rays subject kids to radiation. Depending on where it is done, the dose may be adjusted to the child’s weight, which should be standard, but you may not be assured of that outside of a children’s hospital. Quinonez also pointed out that if you give a chest x-ray to three radiologists to read, you may get three different interpretations. Armed with results from a chest x-ray, kids may end up with unnecessary antibiotics. When this happens often enough, antibiotic resistance may develop.

Repeat imaging is also widespread. How many times have you gone to one doctor, mentioned that you or your child had a specific study done, and you have been stonewalled, told: “We like to do our own.” Again, you have to wonder whether the second or third repeat study in a short interval was really necessary.

Resources You Can Use 

Projects aimed at dialing back unnecessary imaging are getting around. However, from the response to my first post, the news is not getting around enough. For example, the American Board of Internal Medicine/Society of Pediatric Hospital Medicine Choosing Wisely campaign has prepared a tip sheet listing 5 Things Physicians and Patients Should Question. An American Academy of Pediatrics tip sheet provides additional information.

The Image Gently campaign, organized by pediatric radiologists concerned with safety, has a slew of materials that you may find helpful when deciding whether or not to have an imaging study.  Included on their page is a link for a sheet you can use to track all of your child’s medical imaging studies.

The National Cancer Institute has a sheet for health care providers on appropriate use of CT in children. It includes issues that pediatricians and parents should discuss.

 

 

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