Category Archives: JAMA

Three research pieces with a lot of heart

Posted by on September 10, 2013 Comments Off on Three research pieces with a lot of heart

Often the most heartening news comes from health research. The past couple of weeks have revealed three worthy of note. All three involve prevention measures, two before a heart attack, and one after.

First, the US Centers for Disease Control and Prevention estimate that 200,000 deaths from heart attacks can be avoided annually. The preventable deaths are concentrated in three areas.

The first area is age, where preventable deaths are concentrated in the 45-64 age cohort.
Preventable deaths by age

The second area is race, where African-American men are at the highest risk of preventable death, 143 out of 100,000.

Preventable deaths by race

Finally, the deaths are concentrated geographically in the South-Central Region.
Preventable deaths by region

Second, a study from Britain and India, published in the Journal of the American Medical Association (JAMA) found that a single pill or “polypill” with fixed doses of aspirin, anti-hypertensive, and cholesterol-lowering drugs was statistically more effective than offering separate prescriptions. While physicians point out that this approach limits flexibility, greater variation of dosage combinations in polypills is a promising approach.

Polypill study

Third, a study in JAMA Internal Medicine found that even after a heart attack, better diet, as measured with Alternative Healthy Eating Index (AHEI 2010), resulted in lowered mortality.

The good news is that either before, or failing that, after a heart attack, the good practices of medication adherence and reduction of risk factors such as poor diet, can improve our survival as individuals. Furthermore, we can move the needle in a better direction by focusing our educational and interventional efforts on those under 65, African-American, residing in the South-Central United States.

The things we already know–but don’t often do

Posted by on July 15, 2013 Comments Off on The things we already know–but don’t often do

There is the old Middle Eastern story of the one who journeyed East in search of wisdom. He came upon a stone where he read, “Turn me over.”
He picked up the stone and read on the underside: Why do you seek new knowledge when you do not use that which you already have?

A recently reported Swedish study that followed 71,000 individuals over a 13-year period found that consuming less than five daily servings of fruits and vegetables was associated with higher mortality and shorter survival periods. Those eating one serving of fruit daily lived 19 months longer on average, while those eating 3 servings of vegetables lived 32 months longer.

Now by itself, this is not very surprising. We know that heavy meat consumption is linked to colorectal cancer, particularly in combination with genetic mutations, as described in a recent issue of Smithsonian Magazine. So, the possibility that a different diet would be protective, even by contrast, makes some sense.

Fornaciari subsequently analyzed bone collagen of King Ferrante and other Aragonese nobles, revealing a diet extremely reliant on red meat; this finding may correlate with Ferrante’s cancer. Red meat is widely recognized as an agent that increases risk for mutation of the K-ras gene and subsequent colorectal cancer. (As an example of Ferrante’s carnivorous preferences, a wedding banquet held at his court in 1487 featured, among 15 courses, beef and veal heads covered in their skins, roast ram in a sour cherry broth, roast piglet in vinegar broth and a range of salami, hams, livers, giblets and offal.)

In a similar vein, one out of three Americans suffers from hypertension (high blood pressure), a major risk factor for serious cardiovascular events such as stroke and heart attack. A recent study in JAMA showed that 18 months after the beginning of a study in which the experimental group did home blood pressure monitoring along with pharmacist case management, 71.8 percent had controlled blood pressure compared to the control group with usual care at 57.1 percent.

It would be easier if we had pills that would lower our body weight or a vaccination against high blood pressure. We don’t. But we have knowledge that we are not using: walk more, eat less processed foods and more whole grains, vegetables, and fruits, monitor blood pressure and pulse regularly. No, it is not magic–just the best that we can do.

Does the US face a shortage of primary care physicians? Part I

Posted by on April 1, 2013 Comments Off on Does the US face a shortage of primary care physicians? Part I

Several recent studies and news stories suggest that the US faces a physician shortage, particularly in primary care. Access to health care requires not only insurance but adequate numbers of health care providers such as physicians and nurses, among others. Theoretically, we could imagine everyone in the country with adequate insurance but an insufficient number of practitioners to meet their needs.

Pauline W. Chen M.D., for example, asks Where Have All the Primary Care Doctors Gone?

The obvious solution is to graduate more doctors, but three years ago the Wall Street Journal stated that Medical Schools Can’t Keep Up with the expanding number of insureds. A graphic based on data from the Kaiser Family Foundation shows the geographic nature of the problem.

Doctor Shortage_Kaiser_from WSJ

What the map does not tell us is what the optimal number of physicians per 1000 in the population is, nor does it tell us whether that number varies with the degree of urbanization.   For example, does a geographically dispersed population require more physicians per thousand because the expanse is too great for coverage by one person?

The American Association of Medical Colleges (AAMC) provides the figures quoted in almost all of the stories.

From their website:

AAMC Doc Shortage

But, the AAMC does not suggest that increasing the number of medical students will solve the problem. They point out that medical schools planned a 30 percent increase in medical students by 2016 and were on target to meet that goal.

The problem, according to the lobbying group for medical schools, is the number of residencies, which have not kept pace because of the cap on Medicare-funded residencies in the 1997 Balanced Budget Act. They are calling for removal of the cap by the funding of an additional 4,000 residencies annually.

Not at all coincidentally, the AAMC praises introduction of a bill to create 3,000-4,000 new residencies:

20130315_AAMC_pressrelease

If that would solve the physician shortage that has been alleged, then we could all applaud. However, even if we accept that there is a shortage, that it is related to residencies, and that this proposal increases the necessary residencies, there is another possibility.

What if US medical students will not choose primary care residencies over specialties no matter how many there are. Jacob Goldstein noted in a 2009 WSJ blog that residents in internal medicine often go on to do residencies in more lucrative sub-specialties while

In family medicine, another key supplier of primary-care docs, there isn’t even enough interest among qualified young docs to fill existing residency slots. Hundreds of slots went unfilled this year, and graduates of foreign med schools filled many of the available positions.

Goldstein’s point was validated by a study published in the December 2012 JAMA. The accompanying editorial notes that only 21.5 percent of third-year residents plan to practice in primary care. (to be continued)

The latest in DME: an umbrella

Posted by on March 25, 2013 Comments Off on The latest in DME: an umbrella

When my wife moved to the States from Singapore, she was amazed to find that the umbrellas sold did not list their UV protection. Singapore is 137 km or 85 miles from the equator, and light skin is valued in Chinese culture. So protection from the aging and darkening effect of the sun’s rays has strong cultural underpinnings–unlike the US where there seems to be a tanning salon in every strip mall.

Normally we don’t think of an umbrella as DME (Durable Medical Equipment). However, if DME is home medical equipment you need for your health, then using an umbrella to prevent melanoma seems to qualify. As reported in JAMA Dermatology The researchers Josette R. McMichael, MD, Emir Veledar, PhD, and Suephy C. Chen, MD, MS of Emory University performed a simple, but well-designed experiment: they invited friends to join them in a parking lot, took 3 ultra-violet radiation (UVR) readings, and then opened umbrellas the friends had brought, taking two UVR readings, 1 cm from the individual, and 1 cm from the edge of the umbrella as shown:

Umbrella_uvr_measurement_20130304

There was wide variety in protection among the 22 umbrellas tested, ranging from a white totes® (77%) to a silver Coolibar® (99%). Fourteen were black in color.

Some of the numbers: Umbrella_findings_20130314

As is apparent in the account, the two readings (close and far) were highly correlated. The following scatterplot shows that as the values of each of the two readings are on the axes. The lowest reading shows the greatest protection, so umbrella 6 is the Coolibar®.

Umbrella_uvr_emory_20130304

As the earth warms, we can expect disturbances in the atmosphere that increase our exposure to UVR. Borrowing the style of the 19th century, carrying umbrellas, especially those designed to screen UVR, may be the best we can do.

Bad News for Boomers: Our Parents Were Healthier

Posted by on March 14, 2013 Comments Off on Bad News for Boomers: Our Parents Were Healthier

As Americans we believe in progress, in a better tomorrow, sometimes with a bump in the road or a hiccough, but always a better tomorrow.

The data are in (March 4,2013 edition of JAMA Internal Medicine), and it ain’t happening for boomers. Blood pressure, cholesterol, diabetes, and obesity–all greater than the previous generation.

Boomer_Parent_Comparison_JAMAinternalmed_20130304
Source: The Status of Baby Boomers’ Health in the United States The Healthiest Generation?
Dana E. King, MD, MS; Eric Matheson, MD, MS; Svetlana Chirina, MPH; Anoop Shankar, MD, PhD, MPH; Jordan Broman-Fulks
JAMA Intern Med. 2013;173(5):385-386

Although longevity has risen during the twenty-year gap between the two groups, every other indicator of health, except smoking, has become less favorable. And the pattern is clear.

At the top of the following chart are general measures of health. Then, we can see that lifestyle factors have declined leading to the trends in the last section: declining indicators of cardiovascular health.

We can’t choose to be healthy or not: what we can do is make healthy choices by changing the lifestyle factors.

We are choosing illness at great expense to ourselves, both financially and in quality of life, while continuing to endure longer and sicker lives instead of enjoying healthier lives.

Boomer_Parent_Extract_Comparison