200 Years of the New England Journal of Medicine

It's amazing to see that the January 5th issue of the New England Journal of Medicine marks its 200th anniversary. The NEJM is doing quite a bit to promote this fact and they've published a series of very interesting articles to look back on the history of the journal. You can travel through time and see how medicine has evolved as technological advances have allowed physicians to cure diseases, fight illnesses, and discover new ailments. You can take a tour by visiting: http://nejm200.nejm.org/

Can Congress Make You Buy Broccoli?

There's a fascinating editorial in the New England Journal of Medicine titled, "Can Congress Make You Buy Broccoli? And Why That’s a Hard Question." The authors are from the Department of Health Law, Bioethics, and Human Rights, Boston University School of Public Health, Boston. It was an interesting article, given that people are now debating the constitutionality of the Affordable Care Act (ACA). The authors point out four major reasons why the broccoli question is so difficult to answer. You can read the NEJM article here.

Telemonitoring in Patients with Heart Failure

Telemonitoring to Improve Heart Failure Outcomes (Tele-HF) was a multicenter, randomized, controlled trial designed to determine whether telemonitoring would reduce the combined end point of readmission or death from any cause among patients recently hospitalized for heart failure. What did you think about the findings published in the New England Journal of Medicine (NEJM)? The authors start by saying that "Small studies suggest that telemonitoring may improve heart-failure outcomes, but its effect in a large trial has not been established." Then, they conclude the paper with "Among patients recently hospitalized for heart failure, telemonitoring did not improve outcomes." Is this the final conclusion, or are we going to start over with the application and evaluation of newer telemonitoring technologies?

The authors definitely looked at a large sample of heart failure patients. 1653 patients were randomized to undergo either telemonitoring (826 patients) or usual care (827 patients). Telemonitoring was accomplished by means of a telephone-based interactive voice-response system that collected daily information about symptoms and weight that was reviewed by the patients' clinicians.

That type of telemonitoring technology sounds a bit archaic to me, but maybe it was considered "state of the art" for 2007. As we see advances in telemonitoring technology, what will we find in future studies?

Cell Saver blood-recovery system (Haemonetics)

I was reading about a medical case the other day in the New England Journal of Medicine about a "Pregnant Woman with Abdominal Pain and Fluid in the Peritoneal Cavity." The management of this patient involved the use of the Cell Saver blood-recovery system (Haemonetics). The Cell Saver system recovered approximately 600 ml of red cells. That's quite impressive. Here's some information about this technology (from the company's website:

Haemonetics pioneered intraoperative cell salvage. Since its introduction in 1972 our Cell Saver® Autologous Blood Recovery system led the industry to become the standard of care.

The Cell Saver 5+ system is designed for surgeries like CABG, valve replacement, trauma, transplant, and other procedures where medium- to high-volume blood loss occurs. With the ability to deliver between 50-60% hematocrit and to remove nearly all traces of undesirable components such as free hemoglobin, the Cell Saver system is the standard of care and a critical tool to help avoid unnecessary allogeneic transfusions. And in a recent lab test, SmartSuction Harmony® surgical suction system significantly reduced hemolysis. Based on this finding, when a SmartSuction Harmony device is used with the Cell Saver system there may be an increase in the number of viable red blood cells reinfused to patients.

"Strategic napping" for medical and surgical residents?

How would you feel if your surgeon had just waken up from a "strategic nap" before operating on your brain? Here's a snippet from a recent New England Journal of Medicine commentary titled, "The ACGME’s Final Duty-Hour Standards — Special PGY-1 Limits and Strategic Napping." You'll see that I've highlighted the section on strategic napping:

On September 28, the Accreditation Council for Graduate Medical Education (ACGME) released new standards to which residency programs must adhere or risk losing their accreditation. Recognizing societal demands for improved patient safety, the task force that developed the standards has embraced stricter duty-hour limits and greater supervision for trainees in the first postgraduate year (PGY-1). The new standards reflect many of the recommendations made by the Institute of Medicine (IOM) in a 2008 report1 but differ from them on one critical issue — how graduate medical education (GME) programs can best prevent harmful medical errors committed by sleep-deprived residents. The IOM recommended that resident shifts longer than 16 hours include an uninterrupted 5-hour sleep period. The ACGME task force concluded that such a long sleep period was unworkable, instead recommending “strategic napping” during long shifts.

Are we kidding here?  Do we really think that we're going to reduce medical errors by ensuring that our medical and surgical residents are taking "strategic naps?"

Accountable Care Organizations

What do you know about Accountable Care Organizations or ACOs? Is this the Silver Bullet that will fix the healthcare crisis?

Dr. Thomas Lee moderates a roundtable discussion addressing questions about the move toward ACOs under the Affordable Care Act. View the video of this NEJM roundtable discussion and contribute your comments.

Thomas H. Lee, M.D., Lawrence P. Casalino, M.D., Ph.D., Elliott S. Fisher, M.D., M.P.H., and Gail R. Wilensky, Ph.D.
N Engl J Med 2010; 363:e23October 7, 2010

The new NEJM.org

The New England Journal of Medicine (NEJM) website has been redesigned.  Have you visited the "new" NEJM.org?

New features including Specialty Pages, the NEJM Archive, and My NEJM are among the new content and services highlighted.

• The search function has improved and site navigation is much easier. 
• The multimedia content is easier to navigate. If you're looking for an interactive medical case or a video, then you'll find it easily under the "multimedia" section under "articles."
• They've also added a social networking capability so that physicians and other clinicians can interact with other readers and have conversations about the content. 
• Looking for an archived article? You can probably find it as a PDF on the new NEJM.org. I was reading an article published in 1833 (titled, "Fetid Abscesses — Remarks on the Fetid Abscesses Which Frequently Form in the Neighborhood of Mucous Membranes")

I'm impressed by the way NEJM.org has been redesigned and  I look forward to spending more time on this site.

Sensor-augmented insulin pump therapy for type 1 diabetes

We've seen some major advances in diabetes, insulin pumps, and glucose meters. I'm still waiting for the day when someone will announce that we have a fully functional artificial pancreas that doesn't require any user-input.  Then, we'll have a truly closed-loop system that doesn't require any modifications from the user. A patient with type 1 diabetes could eat anything and this artificial pancreas would adjust the insulin dosages and regulate blood sugar like a real pancreas.

The New England Journal of Medicine (NEJM) recently published several articles about some technology advances in the care of patients with diabetes. Those articles are:

• Effectiveness of Sensor-Augmented Insulin-Pump Therapy in Type 1 Diabetes
• Continuous Glucose Monitoring — Coming of Age

We're probably going to see an increase in the use of continuous glucose monitors among patients with either type 1 or type 2 diabetes. Will this eventually become the "standard of care?" Right now, many people are unable to afford continuous glucose monitors and sensor-augmented pumps. How will this change over the next decade? Perhaps the biggest question is: who's going to pay for this expensive technology? If you're on the government-sponsored "public option" insurance plan, will you get coverage for this type of technology?

Glomus tympanicum

What's fun about medicine is that you're constantly learning. In this week's New England Journal of Medicine (NEJM), there's a little photo (and video if you're online) of a lesion in someone's hear. The person was a 50-year-old woman who complained of some ear ringing (tinnitus) that was pulsatile.

Wouldn't you know it? It's glomus tympanicum.  Sorry, but I don't remember learning about this in medical school.  You won't find any information on Wikipedia either, so you'll have to do some traditional research to learn about it.

2 great medical technology articles in this week's NEJM

This week's New England Journal of Medicine (NEJM) has some great articles that focus on medical technology. The first is titled, "Robot-Assisted Therapy for Long-Term Upper-Limb Impairment after Stroke." In this study, the investigators found:

In patients with long-term upper-limb deficits after stroke, robot-assisted therapy did not significantly improve motor function at 12 weeks, as compared with usual care or intensive therapy. In secondary analyses, robot-assisted therapy improved outcomes over 36 weeks as compared with usual care but not with intensive therapy. (ClinicalTrials.gov number, NCT00372411 [ClinicalTrials.gov] .)

The other fascinating article is titled, "An Entirely Subcutaneous Implantable Cardioverter–Defibrillator." We're not just talking about the body of the defibrillator. We're also talking about the leads. Can you imagine a defibrillator that doesn't require transvenous leads? Here's what the authors found:

In small, nonrandomized studies, an entirely subcutaneous ICD consistently detected and converted ventricular fibrillation induced during electrophysiological testing. The device also successfully detected and treated all 12 episodes of spontaneous, sustained ventricular tachyarrhythmia. (ClinicalTrials.gov numbers, NCT00399217 [ClinicalTrials.gov]  and NCT00853645 [ClinicalTrials.gov] .)

It's great to see how technology is changing the way we practice medicine. To read these articles, visit the NEJM (May 13, 2010 issue).

Effect of Bar-Code Technology on the Safety of Medication Administration

There's a great article in the The New England Journal of Medicine (NEJM) titled, "Effect of Bar-Code Technology on the Safety of Medication Administration." The use of technology in hospitals can significantly reduce medical errors.

Background: Serious medication errors are common in hospitals  and often occur during order transcription or administration  of medication. To help prevent such errors, technology has been  developed to verify medications by incorporating bar-code verification technology within an electronic medication-administration system (bar-code eMAR).

Conclusions: Use of the bar-code eMAR substantially reduced the rate of errors in order transcription and in medication administration as well as potential adverse drug events, although it did not eliminate such errors. Our data show that the bar-code eMAR is an important intervention to improve medication safety. (ClinicalTrials.gov  number, NCT00243373 [ClinicalTrials.gov] .)

You can access the The New England Journal of Medicine (NEJM) abstract here: http://content.nejm.org/cgi/content/short/362/18/1698

Social Media and Physicians on the NEJM

You don't see many articles on social media on the New England Journal of Medicine (NEJM). Here's one that may be of interest that starts with the following Editor’s Note:

“Social media has had a dramatic impact on the way the medical community communicates among its members and to the outside world. While it may be appropriate and safe to share deidentified cases or aggregate information with peers to ascertain the legitimacy of specific clinical approaches, research findings, policy issues, and professional needs or support, there are uses that pose potentially serious legal risks and consequences. These include the dissemination of information on specific patients, resulting in HIPAA violations, boundary breaches for “befriending” patients, and practicing medicine in jurisdictions where the clinician is not licensed. When using social media, physicians should ensure that they act responsibly and respect physician-patient confidentiality.”

http://www.nejmjobs.org/career-resources/social-media-and-physicians.aspx

Do you remember what causes purple urine?

In medical school, we like to learn about zebras instead of horses. What I mean is that if you hear hoof beats, are you more likely to think about horses or zebras?  We simply don't see rare diseases (zebras) because we tend to see more common diseases (horses). What's common is common. What's common is also more likely to present in an uncommon fashion.

So, what causes purple urine?

Here's the explanation from the NEJM (New England Journal of Medicine):

Purple discoloration can occur in alkaline urine as a result of the degradation of indoxyl sulfate (indican), a metabolite of dietary tryptophan, into indigo (which is blue) and indirubin (which is red) by bacteria such as Providencia stuartii, Klebsiella pneumoniae, P. aeruginosa, Escherichia coli, and enterococcus species.

When's the last time you saw any purple urine? To read more about purple urine on the NEJM, click here

More cardiology news from the ACC and the NEJM

This has been quite a week in the world of cardiology! So much is happening at the American College of Cardiology (ACC) meeting and the New England Journal of Medicine (NEJM).

Take a look at the list of recent NEJM publications:

Published Online March 15, 2010

• ORIGINAL ARTICLE -Lenient versus Strict Rate Control in Patients with Atrial Fibrillation
• EDITORIAL -Rate Control in Atrial Fibrillation
• ORIGINAL ARTICLE -Duration of Dual Antiplatelet Therapy after Implantation of Drug-Eluting Stents
• EDITORIAL -Optimal Duration of Clopidogrel Use after Implantation of Drug-Eluting Stents — Still in Doubt

Published Online March 14, 2010

• ORIGINAL ARTICLE -Effect of Nateglinide on the Incidence of Diabetes and Cardiovascular Events
• ORIGINAL ARTICLE -Effect of Valsartan on the Incidence of Diabetes and Cardiovascular Events
• EDITORIAL -Navigating the Choices for Diabetes Prevention
• ORIGINAL ARTICLE -Effects of Combination Lipid Therapy in Type 2 Diabetes Mellitus
• ORIGINAL ARTICLE -Effects of Intensive Blood-Pressure Control in Type 2 Diabetes Mellitus
• EDITORIAL -ACCORD and Risk-Factor Control in Type 2 Diabetes

So, how will the management of cardiovascular disease change now that we have new data related to diabetes, hypertension, and lipids?

ACCORD study data released at the ACC

At the American College of Cardiology (ACC) 2010 Scientific Sessions, some of the hottest news is surrounding the ACCORD (Action to Control Cardiovascular Risk in Diabetes) study.  Data regarding the ACCORD study also got published in the New England Journal of Medicine (NEJM).

In fact, there's an editorial in the NEJM titled, "ACCORD and Risk-Factor Control in Type 2 Diabetes." What's the bottom line?

• When it comes to lipid management in patients with type 2 diabetes: The combination of fenofibrate and simvastatin did not reduce the rate of fatal cardiovascular events, nonfatal myocardial infarction, or nonfatal stroke, as compared with simvastatin alone. The ACCORD study results do not support the routine use of combination therapy with fenofibrate and simvastatin to reduce cardiovascular risk in the majority of high-risk patients with type 2 diabetes.
• When it comes to blood pressure management:  In patients with type 2 diabetes at high risk for cardiovascular events, targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, did not reduce the rate of a composite outcome of fatal and nonfatal major cardiovascular events.

The ACCORD study does not tell us how to optimally manage dyslipidemia in patients with type 2 diabetes. The study also does not tell us what the ideal blood pressure ought to be for patients with type 2 diabetes. 

So, many questions remain unanswered, but we know that aggressive lipid management with combination therapy may not be the best approach. We also know that in blood pressure management, "lower isn't always better." The medical management of diabetes needs to be individualized for each patient.

Don't let this happen to a diabetic patient's foot

My father had type 2 diabetes. He always cared for his feet because I always emphasized the importance of proper foot care. This image on the right is from the New England Journal of Medicine (NEJM) and it shows an ulcerated wound on the foot of a patient who has diabetes. Here's a snippet of the description:

A 61-year-old man with a 15-year history of diabetes and resulting foot neuropathy presented with an ulcer of 3 months' duration overlying the first metatarsal head (Panel A). He was unaware of any recent foot trauma. He usually wore rubber slippers. Close inspection of his footwear revealed that an inconspicuous foreign body was lodged in the area of the slipper underlying the ulcer (Panel B and inset). The patient had been unable to sense the presence of the object against his foot because of his neuropathy. The foreign body was removed, and 6 weeks later the ulcer had healed completely. Ill-fitting footwear and soft-soled footwear penetrated by foreign objects are recognized sources of trauma to neuropathic feet. Regular inspection of feet and footwear is essential to minimize this risk.

There's no reason why this should be happening. If you know anyone who has diabetes, make sure that those individuals are receiving proper foot care.

"The Doctor’s Failure to Cut Costs" by Dr. Pauline Chen in the NY Times

In the NY Times, Dr. Pauline Chen writes an interesting article titled, "The Doctor’s Failure to Cut Costs." She interviews Dr. Howard Brody, professor of family medicine and director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston. Dr. Brody recently wrote an editorial in The New England Journal of Medicine, titled, "Medicine's Ethical Responsibility for Health Care Reform — The Top Five List"

So, is it all about money? No. But, listen to this response from Dr. Brody:

When you combine this love affair with high technology with a reimbursement system that pays so much more for technology — and less for thinking and sitting and talking with patients — you end up with an expensive kind of medicine, which, when practiced by doctors, puts more money into their pockets...
In actual fact, there’s such a low chance that technology will help all these patients.

I agree that the misuse of technology is contributing to soaring health care costs. There are some organizations that even promote "executive health" programs that include expensive medical tests and diagnostic studies (not necessarily based on evidence, but based on strategies that will profit the hospital systems).  I believe that technology can significantly improve the world of medicine and public health, but only if it's used properly.

Do statins increase the risk for diabetes?

According to a new study published in the Lancet:

Statin therapy is associated with a slightly increased risk of development of diabetes, but the risk is low both in absolute terms and when compared with the reduction in coronary events. Clinical practice in patients with moderate or high cardiovascular risk or existing cardiovascular disease should not change.

In this meta-analysis of 13 statin trials, statin therapy was associated with a 9% increased risk for incident diabetes. Statin therapy was associated with a 9% increased risk for incident diabetes

Stay tuned, because this article is likely to generate some very interesting discussions regarding the use of statins. You may have heard the phrase, "statins should be in drinking water." How about the idea of creating a super cardiovascular pill that includes a statin, aspirin, beta blocker, and ACE inhibitor?

Maybe the bigger question is regarding the use of statins for patients who have normal cholesterol levels but who have elevated hs-CRP levels (suggesting systemic inflammation which may lead to cardiovascular disease, even if your lipid levels are normal). I'm referring to the JUPIPTER study published in the New England Journal of Medicine and the recent FDA-approved indication for Crestor (rosuvastatin).

Specifically, this includes men 50 years of age and older and women 60 years of age and older who have an elevated amount of a substance known as high sensitivity C-reactive protein in their blood and at least one additional traditional cardiovascular risk factor such as smoking, high blood pressure, a family history of premature heart disease, or low amounts of high-density lipoprotein or HDL cholesterol, the so-called “good cholesterol.”

Click here to read the entire Lancet article titled, "Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials"

NEJM: Physicians Googling Themselves

What happens if you Google yourself? Did you know that Google has turned into a verb? There are many physicians who are "Googling" themselves to see what they can find.

There's a Perspective article in the NEJM (New England Journal of Medicine) titled, "Googling Ourselves — What Physicians Can Learn from Online Rating Sites." Dr. Shaili Jain writes about various online physician rating websites and the reality of consumerism. Patients are rating physicians and websites like RateMDs, Vitals, Vimo, and RevolutionHealth. How much impact do these websites make? Are physician rating systems really helpful for consumers? In many cases, they may be harmful to physicians, so how should they get handled? What if an angry patient simply wishes to strike back by writing a dishonest (but harmful) review?

You can read the NEJM article by clicking here.

Toothpaste out of the elbow! (yucky!)

OK, this is not technically toothpaste. However, it sure looks like it. This is an image of a man's elbow and it's from the New England Journal of Medicine (NEJM).

A 77-yr-old man renal-cell carcinoma (kidney cancer) presented with painful swelling of his elbow. This white chalky substance was a result of an acute flare of previously asymptomatic, chronic tophaceous gout. Hence, this image receives a heading titled, "Gouty Tophi." To read more, visit the NEJM here.