CMS proposes 21.5% reduction in Medicare payments

Are we going forwards or backwards? CMS is proposing reductions on physician reimbursement for Medicare patients. This may impact over 1 million physicians and nonphysician practitioners who are paid under the Medicare Physician Fee Schedule (MPFS). For 2010, CMS is proposing to include data about physicians’ practice costs from a new survey, the Physician Practice Information Survey (PPIS), designed and conducted by the American Medical Association (AMA). The Medicare law requires CMS to adjust the MPFS payment rates annually based on an update formula which includes application of the Sustainable Growth Rate or SGR that was adopted in the Balanced Budget Act of 1997. This formula has yielded negative updates every year beginning in CY 2002, although CMS was able to take administrative steps to avert a reduction in CY 2003, and Congress has taken a series of legislative actions to prevent reductions in CYs 2004-2009.

Here's the clencher: "Based on current data, CMS is projecting a rate reduction of -21.5 percent for CY 2010."

So, what do you think about that? Will this drive more physicians to move to a cash-only practice? Concierge medicine? Maybe they will stop accepting Medicare.

FDA Approves First Maintenance Drug Therapy for Advanced Lung Cancer

This isn't a new drug, but it's a new indication: "maintenance therapy of advanced or metastatic lung cancer." Alimta was originally approved in 2004 for mesothelioma. Here's the summary straight from the FDA:

The U.S. Food and Drug Administration has approved Alimta (pemetrexed), the first drug available for maintenance therapy of advanced or metastatic lung cancer.

Patients with cancer often receive maintenance therapy to prevent the disease from progressing after their tumor has shrunk or the disease has stabilized in response to chemotherapy. Alimta disrupts metabolic processes that are dependent on the B-vitamin folate, a necessary ingredient for cell replication.

“This drug represents a new approach in the treatment of advanced non-small cell lung cancer,” said Richard Pazdur, M.D., director, Office of Oncology Drug Products in the FDA’s Center for Drug Evaluation and Research. “Typically, patients whose tumors respond to chemotherapy do not receive further treatment after four-to-six chemotherapy cycles. This study demonstrates an advantage in overall survival in certain patients who received Alimta for maintenance therapy.”

Non-small cell lung cancer has several subtypes, including squamous cell, large cell, adenocarcinoma and mixed histology cancers. In a 600-patient clinical trial, people with predominantly squamous cell cancer did not benefit from Alimta. But those with other subtypes of non-small lung cancer survived an average 15.5 months following treatment compared with 10.3 months for patients who received an inactive substance (placebo). All patients in the study received standard medical care.

Reported adverse events included damage to blood cells, fatigue, nausea, loss of appetite, tingling or numbness in the hands and feet, and skin rash.

Alimta initially was approved in 2004 for the treatment of patients with mesothelioma, a cancer frequently related to asbestos exposure. The drug was later approved for the treatment of patients with non-small cell lung cancer whose disease worsened on prior chemotherapy drugs and also as an initial therapy for advanced non-small cell lung cancer.

Alimta is manufactured by Eli Lilly & Co. of Indianapolis.

It's exciting to see advances in cancer treatment that focus on new drugs, biologic agents, and combination approaches. The world of oncology is buzzing with new science and the application of technology such as nanotechnology and targeted molecular therapies. Will we ever discover a cure? I doubt that we'll ever see a magic pill that completely eliminates every type of cancer, but lung cancer is a a highly preventable cancer so hopefully we'll see improved efforts at prevention. The greatest public health impact will be made if we improve our preventive health efforts.

Health IT will be central to the practice of medicine

If you're a healthcare professional, what type of role does health information technology (Health IT, HIT, or HITECH) play in your practice? Do you use an electronic health record (EHR)? Do you have computers in your office/hospital (if you can't imagine not having computers everywhere, try visiting some remote health clinics in Montana and Wyoming). You may have a very old computer and if you're not connected to the Internet, then it really may be a worthless paperweight. I don't know how you'd be reading this if that were the case.

Anyways, with all this talk about healthcare reform, we now see people like Dr. David Blumenthal really pushing for health IT. At the HIT Symposium at MIT, Dr. Blumenthal gave an opening keynote where he shared how health IT will transform healthcare in the U.S. Given that somewhere between $31 billion and $46 billion will be channeled towards health IT, this is a huge amount that will result in more than simple incremental changes. Physicians will be expected to use health IT resources heavily. They must demonstrate meaningful use, otherwise they will not see the incentives that are outlined within the HITECH (health IT) provisions outlined within ARRA (American Recovery and Reinvestment Act).

So, should health IT play a more integral role during medical training?

Search engine keywords for MedicineandTechnology.com

A significant percentage of my visitors come to my site through search engines like Google and Yahoo. Bing is still relatively new, so I don't have much data on that yet. What are people typing to end up here? Here's the list of the top keywords:

• free emr
• medicine and technology
• technology in medicine
• radon levels
• hp battery recall joe kim
• epocrates "blackberry storm"
• medtronic pacemaker
• technology and medicine
• non clinical physician jobs
• which is quieter: dell latitude xt2 or lenovo thinkpad x200
• jobs for doctors without residency
• ckd-epi
• samsca
• swallow syncope
• dr. joseph kim
• medicine and technology blog
• blackberry storm medical applications
• ckd-epi equation
• e-prescribing
• jobs for mds without residency
• lenovo x200 vs dell xt2
• medicine technology
• non clinical careers for physicians
• q1 ultra windows 7
• uloric gout medicine
• handbook of medical informatics

I think this list represents content covered in all 4 of my blogs:
• Medicine and Technology

• Non-Clinical Jobs and Opportunities
• Medical Smartphones
• Mobile Health Computing

Over the last 30 days (the month of June), search engine traffic represented roughly 24% of my site traffic. Before that (the month of May), it represented 17% of visitors.

Is Canada's health system better?

There's an interesting article on CNN titled, "Reality check: Canada's government health care system." According to CNN, the story highlights include the following points:

• Woman with tumor said wait would have been too long; she got costly U.S. treatment
  
• Canadian man with cancer says he was put on fast track for treatment
  
• Sen. Mitch McConnell says U.S.-run program would mimic Canada's problems
  
• Some doctors who spoke to CNN say McConnell doesn't have facts right on waits

Here's a snippet from the story: "The Senate's top Republican, Mitch McConnell, R-Kentucky, asserted several times on the Senate floor last month that a government-run health insurance option, which President Obama and Democrats want, could lead to a government-controlled health care system like Canada's."

I know many Canadians who have traveled to the U.S. to get an MRI or other type of imaging study. Some travel to the U.S. for surgery. If you can afford the luxuries associated with U.S. healthcare (and even concierge medicine), then why not? Right? What happens to all those patients who are unable to afford the luxuries of such healthcare? At least in Canada, you have some level of healthcare coverage. Here in the U.S., millions of people live without any level of healthcare coverage. Why? Because they're not old enough to qualify for Medicare and they have too much to qualify for Medicaid. These days, so many doctors don't accept Medicaid, so what benefit is that anyways?

What will healthcare look like after we go through major reform? Will we mimic the Canadian system on some level? Many are predicting a tiered healthcare system where a basic, universal plan will be available to everyone, and then those who can afford more will basically get more. Who determines what types of medical tests you deserve? The same person who complains of symptoms such as dyspnea, headache, and a cough may get one type of workup in Canada (few, if any tests) and another totally different battery of tests (necessary or unnecessary) here in the U.S. Why such disparities? Do we live in such a litigious society here in the U.S.? (Don't answer that last question) To read the entire CNN story, click here.

Q&A with Medicare about e-prescribing incentives

Medicare can be so confusing. I'm not even talking about Part D and the donut hole (yummy, I love donuts). The e-prescribing incentives can get a bit confusing, especially if you were used to the e-prescribing quality measure that was included in the Physician Quality Reporting Initiative (PQRI) before Jan 1, 2009. To provide some clarity on this topic, let me do a bit of a "Q&A" with Medicare about the e-prescribing incentives. All this content is directly from the HHS.gov website.

Here's the first question:

"What requirements/qualifications are needed to successfully participate in the new Electronic Prescribing (e-prescribing) Incentive Program?"

Answer:

To be a successful e-prescriber for the 2009 e-prescribing Incentive Program, an eligible professional must have adopted a qualified e-prescribing system that employs standards adopted by the Secretary for Part D by virtue of the 2003 Medicare Modernization Act (MMA) and is capable of ALL of the following functions:

• Generating a complete active medication list incorporating electronic data received from applicable pharmacy drug plan(s) if available

• Selecting medications, printing prescriptions, electronically transmitting prescriptions, and conducting all alerts (defined below)

• Providing information related to lower cost, therapeutically appropriate alternatives (if any) (the availability of an e-prescribing system to receive tiered formulary information, if available, would meet this requirement for 2009)

• Providing information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient's drug plan, if available

Two additional criteria must also be met for the incentive program to be a successful e-prescriber and qualify for the incentive: 1) Medicare charges for the e-prescribing measure codes (delineated in the denominator of the measure specification found here) comprise at least 10% of total Medicare Part B allowed charges; and 2) at least 50% of all Medicare Part B patient encounters (denominator-eligible cases) for the e-prescribing measure must be reported during the 2009 reporting period.

Are you ready for a second Q&A? How about this: I'll try to cover 1 key Q&A topic each day over the next few weeks.

Medicine and Technology: Top posts for last week

Here are the most popular posts from the previous week on MedicineandTechnology.com:

1. Physician social networking online

2. Government panel may pull drugs containing acetaminophen

3. Does your doctor Twitter?

4. A remedy for health-care costs?

5. CNN's Sanjay Gupta talks about Michael Jackson's death

6. Epic MyChart

7. Jobs for Physicians with No Residency Experience

8. Medical apps for the Apple iPhone

9. Misguided health article on CNN about CRP

10. Tip for medical students, interns, and residents

Should we eliminate combination products that contain acetaminophen?

So many combination products contain acetaminophen. You'll find them in prescription drugs (like Vicodin and Percocet) as well as in many over-the-counter (OTC) cough/cold medicines. For instance, Nyquil has an equivalent dose of 1000 mg of Tylenol (acetaminophen). If someone took Nyquil for a cold and then took some additional Tylenol for a headache, he could have a serious liver problem in a few days from a Tylenol overdose. Many people don't look at the ingredients of cold/cough medicines and they also don't realize that acetaminophen = Tylenol (just a different name).

Now, the FDA panel focused on prescription combination products that contain acetaminophen. Why? Because the data shows that acetaminophen-related overdoses occur mainly with prescription drugs. Maybe that's because some people are taking Vicodin and Percocet for drug-abuse problems and they're more prone to suicidal tendencies. Perhaps some people are "popping pain pills" to relieve intractable pain.

Regardless, I think that if we're going to change combination prescription drugs, then we should also re-evaluate combination OTC products that contain acetaminophen. Otherwise, consumers may get the wrong message. My hope is that we simply improve labeling and public health awareness but that all the products still remain available.

Happy Independence Day America!

Today is July 4 and it marks Independence Day in the United States. Our country has changed dramatically since 9-11 and I think Independence Day has a revived meaning in this country. As we combat terrorism and fight for freedom, let us continue to pray for our soldiers and their families.

Survival tips for new interns: eating

Since we're in the month of July, I thought I'd share some "survival tips for new interns." If you're a medical student and you're starting your 3rd year clinical clerkships, these same tips may help you survive on the wards. Since the number seven is symbolic of completion, I'll provide 7 tips:

1. Eat whenever you can and always carry snack bars. Sometimes, you're running around like crazy. Your cafeteria might close and you'll miss dinner. It's essential that you eat whenever you can and always carry survival food. Ration that food since you won't know when you'll get to restock your supplies.
2. Keep food in your bag/locker at all times. See above.
   
3. This is not a good time to go on a diet. See above. You may be prone to some serious rebound eating phenomenons.
4. Keep some new, clean zip lock bags in your white coat pocket. You'll never know when you'll be around free food that you can't eat (but you might be able to stuff a cookie into that bag and run along).
   
5. If you're about to die of hunger, offer to buy some snacks for everyone instead of asking, "can I go and eat while the rest of you continue to work?"
   
6. If you carry food in your pockets, avoid things that can melt, get crushed, or leak. I love chocolate, but it can melt and be messy to eat. Chips are great if you like salty crumbs. I love ice cream bars, but not after they've been in my pockets for 2 hrs.
7. If you get really desperate (last resort), you can always play the "I think I gave myself too much insulin and I'm starting to feel hypoglycemic" card. Remember, you don't have to disclose anything about your personal health conditions.
   

Remember the "Symptoms of Inadequate Food Consumption" (according to SurvivalTopics.com - feel free to quote that website):

• Irritability
• Low moral
• Lethargy
• Physical Weakness
• Confusion and disorientation
• Poor judgment
• Weakened immune system
• Inability to maintain body temperature which can lead to hypothermia, heat exhaustion, or even heat stroke.

So, you don't want to blame any of these things listed above to "inadequate food consumption," right? You definitely don't want to exhibit "poor judgment" because of an empty stomach.

My next series of survival tips will be on bathroom use. Here's a preview: always empty your bladder before you perform a paracentesis on a patient with cirrhosis and massive ascites.

Understanding the Medicare e-Prescribing Incentive Program

Do you understand the Medicare e-Prescribing Incentive Program? Don't get this confused with the incentives outlined in ARRA about HITECH. Sorry, let me clarify: The Medicare e-Prescribing Incentive Program is not the same as the recent incentives outlined in the Health Information Technology (HITECH) provisions within the American Recovery and Reinvestment Act (ARRA).

The Medicare e-Prescribing Incentive Program began January 1, 2009 and provides incentives for eligible healthcare professionals who are "successful e-prescribers". We'll define that later. Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorizes a new and separate incentive program for eligible professionals who are successful electronic prescribers (e-Prescribers) as defined by MIPPA. For 2009, e-prescribing incentive amounts will be 2% of the total estimated allowed charges for professional services covered by Medicare Part B and furnished by an eligible professional during the reporting period (one calendar year). 2% may not seem like much, but it can add up quickly.

Previously, there used to be an e-prescribing quality measure that was included in the Physician Quality Reporting Initiative (PQRI). Now, e-prescribing is no longer included in PQRI and it is the quality measure used in the E-prescribing Incentive Program.

One question that often gets asked about the Medicare e-Prescribing Incentive Program is this: "What defines a "qualified' e-prescribing system?" If you're using an EHR that has some type of e-prescribing capability, are you using a "qualified" e-prescribing system?

According to Medicare, there are two types of e-prescribing systems:

• 1) a system for e-prescribing only (a “stand-alone” system), or
• 2) an electronic health record (EHR) system with e-prescribing functionality.

Either of these systems may be used for the incentive program, as long as they are “qualified.” Let's talk about that word now. A qualified system must be able to do the following:

1. Generate a complete medication list that incorporates data from pharmacies and benefit managers (if available)
2. Select medications, transmit prescriptions electronically using the applicable standards, and warn the prescriber of possible undesirable or unsafe situations
   
3. Provide information on lower-cost, therapeutically-appropriate alternatives (for 2009, tiered formulary information, if available, meets this requirement)
   
4. Provide information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s drug plan

So, are you using a "qualified" e-prescribing system? If you're not, then you're missing out on some Medicare incentives.

Hospital worker may have exposed patients to hepatitis C

This is a very sad and disturbing story. A surgical technician has at Rose Medical Center in Denver has admitted to secretly injecting herself in a bathroom and using unclean syringes as replacements for patients. Kristen Diane Parker had hepatitis C, presumably from IV drug use, and she took patient fentanyl injections and replaced them with saline. She worked at Rose from October 2008 to April 2009. So far, nine patients who had surgery there during that time have tested positive for hepatitis C. That is really a shame. Parker should have gotten professional help for her drug addiction. Now, Parker is in federal custody facing three drug-related charges. If she is found to have done serious harm to a patient, she could face up to 20 years in prison. If a patient dies due to her actions, she could face life in prison.

According to CNN, in a statement to police, Parker said, "I can't take back what I did, but I will have to live with it for the rest of my life, and so does everyone else." Rose Medical Center is contacting 4,700 patients who had surgery at Rose during the time Parker was employed there. Another 1,200 patients may have been infected between May 4, 2009, and July 1, 2009, when Parker worked at Audubon Ambulatory Surgical Center in Colorado Springs.

Hepatitis C can be treated, but the treatment regimen isn't easy to take. Advances in antiviral therapies have improved outcomes for hepatitis C and several new and novel agents are in development. Advances in drug development may lead to a quick and easy cure for hepatitis C. Wouldn't that be nice? I know many people who are infected with hepatitis C due to blood transfusions. We (as the medical community) didn't know how to identify hepatitis C before 1992. It was called non-A, non-B viral hepatitis. We now call it hepatitis C. Chronic infection can lead to cirrhosis and liver failure. It can even lead to liver cancer. To read the CNN story, click here.

Contest eaters face serious health issues

In a former life, I was almost a contest eater. Not for speed, but for quantity. That was a very long time ago. Do you ever watch those food eating contests? They are crazy! CNN has a story titled, "Speed eaters gain weight, clog arteries but have few regrets." Maybe they don't have many regrets while they're still young and relatively healthy, but this type of behavior can catch up to you, especially if you're Don Lerman who set a record by eating seven sticks of salted butter in five minutes. During six years of competitive eating, he gained 100 pounds! The average adult in the U.S. gains 1 pound per year. If you gain 100 pounds in 6 years, how many pounds are you gaining each year? (certainly you're above the mean)

In 2007, University of Pennsylvania School of Medicine doctors who specialize in gastroenterology and radiology conducted an experiment on the stomach activities of a competitive eater and an average eater. Do you know what they found? Competitive eaters lacked muscle contractions called peristalsis, which move the food down the digestive tract. The researchers published a paper where they warned about: possible "morbid obesity, profound gastroparesis, intractable nausea and vomiting, and even the need for a gastrectomy." Yikes!

I wonder what we're going to learn about competitive eaters over the next decade. If you exercise, can you eat anything you want to eat? Does exercise give you freedom to eat? (It does for me - that's why I can enjoy ice cream and be guilt-free). Read the CNN story here.

Tip for medical students, interns, and residents

Here's my tip of the day: sew a few pockets inside your white coat. If your white coat already has inside pockets, then you're all set! However, some of you may only have pockets on the outside. If that's the case, then spend some time (or money) to attach pockets to the inside. Why do I think this is useful? If you're a medical student or intern, you'll be carrying around so many papers (and supplies during your surgery rotation) that you won't want everything bulging out on the outside. You can hide some of those items on the inside (and also have better access to urgent items).

Once you're a resident, you may have lighter pockets, but here's where you can also have the chance to carry some items that may be life-saving. When's the last time you carried a Sengstaken-Blakemore tube during your GI/Hepatology rotation? These things can be life-saving (and you won't have time to wait for one if you really need it).

Medicare Part D increases spending on prescription drugs

Is that what you were expecting? In a recent article in the New England Journal of Medicine (NEJM), we see that the authors conclude that "Enrollment in Medicare Part D was associated with increased spending on prescription drugs. Groups that had no or minimal drug coverage before the implementation of Part D had reductions in other medical spending that approximately offset the increased spending on drugs, but medical spending increased in the group that had more generous previous coverage."

Between December 2005 and December 2007, as compared with the increase in the no-cap group, the increase in total monthly drug spending was $41 higher among enrollees with no previous drug coverage, $27 higher among those with a previous $150 quarterly cap, and $13 higher among those with a previous $350 cap. I wonder if the government knew this was going to happen.

The article is titled, "The Effect of Medicare Part D on Drug and Medical Spending." Click here to access the abstract. The authors on this study included: Yuting Zhang, Ph.D., Julie M. Donohue, Ph.D., Judith R. Lave, Ph.D., Gerald O'Donnell, M.S., and Joseph P. Newhouse, Ph.D.

Ethics of concierge medicine

Concierge medicine is often referred to as boutique or retainer-based medical practices. We have seen a surge of physicians and medical groups converting to this type of model over the last several years. Why? Because you can get paid more for seeing fewer patients. Sounds almost ironic, doesn't it? In a typical concierge practice model, patients pay an annual retainer fee outside of insurance to gain greater access to their physician. What does this mean? It means that you may be able to call your doctor directly. Forget about answering services. Also, it may mean that you doctor will see you in the middle of the night if you develop chest pain. Forget waiting in the ER if you need to get admitted by your physician.

If political leaders like presidents can have concierge-type medical care, then is it unethical to offer it to other rich and powerful people? If a billionaire hires you to live and work as a personal doctor for his/her family, would it be unethical to do that? I think the bigger issue revolves around the accessibility to care. If you're the only doctor in a 50 mile radius and you decide to convert your practice, then there may be some ethical issues concerning the accessibility to care and medical need. A related topic deals with the acceptance of Medicaid insurance. Many physicians are choosing not to accept Medicaid because the reimbursement is so low. Eventually, a cash-only model may become the prominent model (especially if the government steps in and offers some level of universal health coverage).

Let's evaluate the ethics behind concierge medicine:

• Autonomy: Probably not an issue.
  
• Beneficence: "the act of doing good things." Well, as long as you offer good care to those who are paying you, you're fine there.
• Non-Maleficence: "do no harm." Well, this is where concierge medicine may have a problem. If you move to a brand new area to set up your concierge medical care, then you may be fine. However, as I mentioned above, if you're the only doctor in a remote area and you decide to convert your practice, then there may be some ethical issues concerning the accessibility to care and medical need. You may be "harming" those who are unable to afford your prices.
  
• Informed consent: Don't see any issues here as long as your contract is well-written.
• Confidentiality: Probably not an issue.

The AMA Principles of Medical Ethics ends with this statement: "A physician shall support access to medical care for all people." Hmm, not sure how this relates to concierge medicine.

However, the AMA Principles of Medical Ethics also has this statement: "A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care."

Healthcare Information Technology Standards Panel

Have you heard of the Healthcare Information Technology Standards Panel (HITSP)?

Let me share a snippet from their "about us" section of their website: "The mission of the Healthcare Information Technology Standards Panel is to serve as a cooperative partnership between the public and private sectors for the purpose of achieving a widely accepted and useful set of standards specifically to enable and support widespread interoperability among healthcare software applications, as they will interact in a local, regional and national health information network for the United States... The Panel's work is driven by a series of priorities (i.e., Use Cases) issued by the American Health Information Community (AHIC). HITSP produces recommendations and reports in Interoperability Specifications and related Constructs. These work products are intended to be equally applicable to the developing Nationwide Health Information Network for the United States (NHIN) and also to community and regional health information exchange networks."

OK, if that didn't impress you, then maybe this will: "HITSP is a strategic partnership established through a contract with the U.S. Department of Health and Human Services."

On July 9, The Healthcare Information Technology Standards Panel (HITSP) is identifying the standards that will support the exchange of healthcare information across the United States. Titled, "Health Information Exchange (HIEs) in the Real World," this webinar will cover how HITSP products are being used today by the New England Healthcare EDI Network (NEHEN), Keystone Health Information Exchange (KeyHIE), and Vermont Information Technology Leaders, Inc. (VITL). Interested in this free webinar? Click here for more information.

The HITSP is administered by the American National Standards Institute (ANSI) in cooperation with strategic partners including the Healthcare Information and Management Systems Society (HIMSS), the Advanced Technology Institute (ATI), and Booz Allen Hamilton.

NPR: Young Doctors Weigh In On Health Care

I want to thank my friend Roland for pointing me to this link. There's an interesting NPR segment titled, "Young Doctors Weigh In On Health Care." Here's the description of the clip:

"Two young doctors, just finishing up their residencies, discuss the decisions behind their career choices. Nicole Loeding is going into primary care, while Brian Southern, after becoming disillusioned with primary care, has chosen pulmonary critical care."

How do medical students choose their specialties? Why do some decide to pursue a career in primary care? As we go through healthcare reform, will the interest in primary care increase or decrease? Will more physicians choose to leave clinical practice to pursue non-clinical careers?

The 8 minute NPR segment is interesting, but perhaps what's more interesting are the 12 comments that discuss physician salaries. So how much do primary care doctors make? It really depends on your geography and your patient volume. To access the NPR segment, click here.

E. coli in beef leading to hospitalizations

MSNBC is reporting that at least 12 hospitalizations have occurred due to E. coli contamination in beef. Some of these patients have even suffered kidney failure. According to the Centers for Disease Control and Prevention (CDC), at least 23 people in nine states may have become ill after eating beef produced by JBS Swift Beef Co. of Greeley, Colo. I think it's time to make sure my beef is cooked well-done for a while. Forget eating medium-rare or even medium steaks. To read the full story on MSNBC, click here.

Reducing cell phone radiation exposure

Technology Review - I love that magazine. It's published by MIT and I just got my copy today because I'm on the MIT alumni mailing list. On the Tech Review blog, there's a post titled, "How to Reduce Cell-Phone Radiation Exposure." The author writes that a new network architecture could dramatically reduce the radiation exposure from cell phones. Wouldn't it be great if we could reduce radiation and boost battery life? What if we could enhance existing networks by adding large numbers of base stations that only receive signals and are connected up to the rest of the network via a landline or a line-of-sight microwave link? There's an Israeli startup called Greenair Wireless and that's what they're trying to do. What's the big deal about radiation exposure? Chronic exposure to radiation may be linked to a higher risk of cancer. So do cell phones cause brain cancer? It's still a controversial topic and I don't think we'll have a clear answer for a while. In the meanwhile, anything that we can do to reduce that exposure would be warmly welcomed by all of us who are now so dependent on mobile phones and smartphones.

FDA Approves Multaq (dronedarone) to Treat Heart Rhythm Disorder

This is straight from the FDA RSS feed:

FDA Approves Multaq to Treat Heart Rhythm Disorder.

The U.S. Food and Drug Administration has approved Multaq tablets (dronedarone) to help maintain normal heart rhythms in patients with a history of atrial fibrillation or atrial flutter (heart rhythm disorders). The drug is approved to be used in patients whose hearts have returned to normal rhythm or who will undergo drug or electric-shock treatment to restore a normal heart beat.

Multaq may cause critical adverse reactions, including death, in patients with recent severe heart failure. The drug’s label will contain a boxed warning, the FDA’s strongest warning, cautioning that the drug should not be used in severe heart failure patients.

“Multaq represents a therapeutic innovation for treatment of the heart rhythm disorder of atrial fibrillation,” said Norman Stockbridge, M.D., Ph.D., director of the Division of Cardiovascular and Renal Products in the FDA’s Center for Drug Evaluation and Research.

In a multinational clinical trial with more than 4,600 patients, Multaq reduced cardiovascular hospitalization or death from any cause by 24 percent, when compared with an inactive pill (placebo). Most of that effect represents reduced hospitalizations, especially hospitalizations related to atrial fibrillation. Atrial fibrillation and atrial flutter cause the heart to beat abnormally fast and sometimes prevent blood from being properly pumped out of the heart.

The most common adverse reactions reported by patients in clinical trials were diarrhea, nausea, vomiting, fatigue and loss of strength. Multaq is manufactured by Paris-based sanofi-aventis.

So, let's talk about this for a few minutes. Dronedarone is a brand new drug and it may replace the use of amiodarone in many patients who have afib. Atrial fibrillation is a common condition that you get to manage in the hospital setting. It's not a lot of fun if you have to run around to titrate Cardizem drips all day. Amiodarone is associated with some significant toxicities, including pulmonary toxicity leading to interstitial pneumonitis and other lung problems. It's great to see that we have other alternatives for patients with afib. Speaking of afib, medical students often like to use a mnemonic to help them remember the different causes of afib:

PIRATES:

• Pulmonary: PE, COPD
• Iatrogenic
• Rheumatic heart: mirtral regurgitation
• Atherosclerotic: MI, CAD
• Thyroid: hyperthyroid
• Endocarditis
• Sick sinus syndrome

Inovio developing a swine flu vaccine

Inovio is developing a swine flu vaccine. Here's the headline: "Inovio Biomedical, National Microbiology Laboratory, and University of Pennsylvania to Evaluate Candidate DNA Vaccines Against “Swine” Influenza A (H1N1)"

Inovio has established a new collaboration with the National Microbiology Laboratory of the Public Health Agency of Canada and the University of Pennsylvania to further evaluate Inovio DNA vaccine candidates against swine influenza A (H1N1) virus. Dr. J. Joseph Kim (no, that's not me), Inovio’s CEO, stated, “The current swine flu outbreak highlights the fact that the world cannot rely solely on the “catch-up” strategy of influenza vaccine design. We need vaccines that provide at least some broad protective capability against evolving seasonal influenza strains and those with pandemic potential. We have already achieved significant validating data in large animal models regarding the ability of Inovio’s consensus vaccines to protect against unmatched strains of different influenza sub-types and look forward to the data resulting from this collaboration of vaccine experts.”

Mississippi tops U.S. obesity rankings

The state of Mississippi tops U.S. obesity rankings according to CNN. In fact, it's held this title for the 5th year in a row - for both adults and children. 32.5% are obese in Mississippi. In addition, 44.4 percent of Mississippi children ages 10 to 17 are classified as overweight or obese, the study found. This is a serious public health problem and the state of Mississippi desperately needs help to control this obesity epidemic. Unfortunately, Southern style cooking is often rooted in deep fried foods, so it's going to be very difficult to change cooking patterns that are deeply ingrained in Southern culture. Obesity is linked to a variety of health problems such as diabetes, heart disease, and hypertension. Many people who are obese really struggle to lose weight and keep it off. So what's the solution? Bariatric surgery?

This is where preventive medicine needs to take a very active role. Educational efforts alone are not enough. Interventions must begin in the classroom as children learn and develop lifestyle habits. Unless things change at a fundamental level, the problem will only continue to get worse. Perhaps the government needs to channel some money into structured weight loss programs. People living below the poverty line probably can't afford to pay for Weight Watchers or Jenny Craig. They also can't afford expensive gym memberships. They are often eating unhealthy foods and they often lack access to exercise facilities. To read the entire CNN story, click here.

How much swine flu vaccine will we need?

How much is enough? That's the question of the year as we prepare for the worst part of the swine flu pandemic. We know that swine flu (influenza H1N1) has spread throughout the U.S. and healthy people are dying from this common illness.

CNN has a story titled, "CDC: U.S. may need 600 million swine flu vaccine doses." Is 600 million doses going to be enough? What if we need more? Each adult will probably need two separate doses of vaccine (two shots, ouch!). According to CNN, "Congress passed a supplemental appropriation for $7.5 billion, which President Obama recently signed, to cover the costs of preparing for the virus, which includes a vaccination campaign." New and old pharmaceutical companies around the world are racing to prepare a safe and effective swine flu vaccine. Will they be prepared before it's too late? What if they're not safe? These are some of the questions that health officials are facing. To read the CNN story, click here.

Are you avoiding the hospitals because of new interns and residents?

July is when new interns and residents begin working in teaching hospitals. Fresh medical school graduates now get to wear long white coats (at least in most hospitals) and go around being called "doctor." No longer are they fourth year medical students. No longer do they have those short white coats. No longer do they need to find someone to sign a prescription. They have the power to write prescriptions (at least is most states) and they also have the power to control medical students (well, let's not get on this right now).

So, are you avoiding the hospital because these fresh interns are getting acclimated and oriented? How would you feel if your "doctor" has only been a doctor for a few days?

Well, I suppose if you're sick, you really don't have any choice. Perhaps you'll want to go to a private hospital and avoid teaching institutions. If you do that, how will these students and doctors-in-training learn anything?

Do you know how to differentiate an intern from a resident? Some hospitals use different white coats (or they place a "mark" on the intern coat). If you see a young-looking doctor wearing a brand long new white coat, you may wonder, "how new is that long white coat?"

Misguided health article on CNN about CRP

CNN has a story that has a misguided title (in my opinion). The story is titled, "Study suggests C-reactive protein doesn't cause heart disease." If we focus on causality, we may be missing the boat.

C-reactive protein (CRP) may not cause heart disease, but it may be a marker of underlying inflammation. Chronic inflammation may lead to coronary heart disease (CHD). If that's all true, then the title of the story can be misguiding. We often think in terms of cause and effect. If you have blood stasis (not moving), then you can form a blood clot. Cause and effect. So, if cardiovascular inflammation causes CHD, can you have inflammation without an elevation in CRP? Can you also develop CHD without any inflammation if you also have really high cholesterol levels? I think we're learning that the pathophysiology of CHD is not as simple as we learned about in medical school.

Well, if CRP doesn't cause heart disease, so what? What if CRP is an indicator of heart disease? That's the real question. It may not have a causal relationship, but that statement may be misguiding.

The JUPITER study published in the New England Journal of Medicine (NEJM) showed that a cholesterol-lowering drug Crestor (rosuvastatin) significantly reduced the incidence of major cardiovascular events in healthy-appearing patients who had low and normal cholesterol levels. This was such a groundbreaking study that it stirred significant controversy about CRP and the high-sensitivity CRP (hs-CRP).

CNN quotes the lead author of the JUPITER study in this story as "Another leading CRP researcher who isn't so sure about the findings published in the Journal of the American Medical Association (JAMA)." Dr. Paul M. Ridker, the director of the Center for Cardiovascular Disease Prevention at Brigham and Women's Hospital, in Boston, Massachusetts, said: "A null Mendelian randomization may not mean very much... While it does not support causality, I don't think most genetic statisticians believe it excludes a causal pathway either."

Are you familiar with Mendelian Randomization and Genetic Association Studies? Good, me too. The JAMA studied used this as one of its steps: " A mendelian randomization study for the most associated single-nucleotide polymorphism (SNP) in the CRP locus in our data together with published data on CRP variants with CHD let us assess the potential causal association of CRP with CHD." Did you catch all that? Good, me too.

Dr. Ridker argues that clinicians should still measure hs-CRP for the following reasons:

• A, it predicts vascular risk even when cholesterol is low and other risk factors are absent, and,
  
• B, because we have clinical trial data demonstrating that if you have an increased level of [hs-CRP], you will live longer and have fewer heart attacks and strokes if you take a statin.

Dr. Ridker goes on to say: "I have always felt that CRP is a good clinical biomarker of inflammation (and high vascular risk) but that it is inflammation that is likely to be causal for atherosclerosis, not CRP itself." To read the CNN story, click here.

CCHIT Unveils New Paths to Certification

Is your electronic health record (EHR) system certified by the CCHIT?

The CCHIT (Certification Commission for Healthcare Information Technology) now offers three different certification approaches to replace the current single one. According to Mark Leavitt, M.D., Ph.D., Commission chair, “The rate of EHR adoption must now be tripled to meet the ambitious ARRA (American Recovery and Reinvestment Act) timelines, so we’re broadening access to certification, widening our previous single-lane road to the equivalent of a three-lane freeway... We need to serve a more diverse spectrum of providers and offer a wider range of EHR technology options from which to choose.”

The three different approaches are:

• A rigorous certification for comprehensive EHR systems that significantly exceed minimum Federal standards requirements. This certification (EHR-C) would be targeted to the needs of providers who want maximal assurance of EHR capabilities and compliance

• A new, modular certification program for electronic prescribing, personal health records, registries, and other technologies. Focusing on basic compliance with Federal standards and security, the EHR-M program would be offered at lower cost, and could accommodate a wide variety of specialties, settings, and technologies. It would appeal to providers who prefer to combine technologies from multiple certified sources.

• A simplified, low cost site-level certification. This program would enable providers who self-develop or assemble EHRs from noncertified sources to also qualify for the ARRA incentives.

Development of the new certification options is scheduled to begin in this month (July).

FDA: Boxed warning for Chantix and Zyban

FDA: Boxed Warning on Serious Mental Health Events to be Required for Chantix and Zyban

The U.S. Food and Drug Administration today announced that it is requiring manufacturers to put a Boxed Warning on the prescribing information for the smoking cessation drugs Chantix (varenicline) and Zyban (bupropion). The warning will highlight the risk of serious mental health events including changes in behavior, depressed mood, hostility, and suicidal thoughts when taking these drugs.

The FDA press release has this comment from Janet Woodcock, M.D., director, the FDA’s Center for Drug Evaluation and Research: “The risk of serious adverse events while taking these products must be weighed against the significant health benefits of quitting smoking... Smoking is the leading cause of preventable disease, disability, and death in the United States and we know these products are effective aids in helping people quit.”

Wellbutrin (another branded name of bupropion) and generic versions of bupropion will also require this warning. Chantix is marketed by Pfizer and Zyban is marketed by GlaxoSmithKline (GSK). Before we know it, every drug out there will have a black box warning and people might simply start to ignore them. Will we soon need another form of a boxed warning?

Medicine and Technology: Top posts for June 2009

Here are the most popular posts for the month of June 2009 on MedicineandTechnology.com

1. Jobs for Physicians with No Residency Experience

2. Sermo vs. Ozmosis: Physician Social Networking

3. A free EMR Solution?

4. What happens if you eat magnets?

5. Medical Software for the BlackBerry Storm

6. Non-Clinical Careers and Opportunities for Physicians

7. How Do You Calculate GFR?

8. Do You Have Cell Phone Elbow?

9. Twitter Growth: the Last 2 Months

10. Epic MyChart