Blog Commentary
Forth-six years ago on July 30, President Lyndon B. Johnson signed the Social Security Act of 1965 into law and created Medicare and Medicaid. Enacting universal, single-payer healthcare for the country's elderly and indigent was a long struggle that began during Harry Truman's presidency.
Medicare and Medicaid were part of Johnson’s Great Society, which had two primary goals: to eliminate poverty and to eliminate racial injustice. After his landslide victory over Barry Goldwater in 1964, Johnson and his Democratic Congress enacted forward-thinking reforms that were reminiscent of the New Deal and began the full-on War on Poverty, which reduced the poverty rate significantly over the subsequent 10 years. Many important Great Society programs– aimed at improving labor conditions, healthcare, and education for poor and working class Americans– are still in existence: Medicare, Medicaid, food stamps, student loans for college, work study, and Head Start. These programs were strengthened under Republican Presidents Richard Nixon and Gerald Ford.
Today, there are forces on the right who would redesign Medicare, while there are equally vocal forces on the left who would extend Medicare to all Americans in order to provide universal healthcare coverage.
Kamis, 28 Juli 2011
Rabu, 27 Juli 2011
Testosterone Deficiency: A Comprehensive Review
Testosterone Deficiency is a highly prevalent and under-diagnosed condition associated both with aging and common medical comorbidities, including metabolic syndrome and cardiovascular disease. Early evidence suggests that testosterone replacement therapy may reverse early diabetes and improve overall male health. A comprehensive review of testosterone deficiency was published in the July issue of The American Journal of Medicine.
Abstract
Testosterone deficiency (TD) afflicts approximately 30% of men aged 40-79 years, with an increase in prevalence strongly associated with aging and common medical conditions including obesity, diabetes, and hypertension. A strong relationship is noted between TD and metabolic syndrome, although the relationship is not certain to be causal. Repletion of testosterone (T) in T-deficient men with these comorbidities may indeed reverse or delay their progression. While T repletion has been largely thought of in a sexual realm, we discuss its potential role in general men's health concerns: metabolic, body composition, and all-cause mortality through the use of a single clinical vignette. This review examines a host of studies, with practical recommendations for diagnosis of TD and T repletion in middle-aged and older men, including an analysis of treatment modalities and areas of concerns and uncertainty.
Case Study Example
A 52-year-old man of Caucasian descent presented with erectile dysfunction (ED), diminished libido, and fatigue. He took no medications and was otherwise healthy. He was 5 feet, 7 inches tall (170 cm) and weighed 217 pounds (98 kg), with a body mass index of 34 kg/m2 and a waist circumference of 43 inches (109.2 cm). His blood pressure was 135/80 mm Hg. Laboratory values were all normal except for serum total testosterone of 270 ng/dL (9.37 nmol/L) (normal reference range 300-1000 ng/dL [10.4-34.7 nmol/L]) and fasting serum glucose of 110 mg/dL (6.1mmol/L) (normal 67-99 mg/dL [3.7-5.5mmol/L]), indicating a component of metabolic syndrome (MetS).1 What are the diagnostic, prognostic, and therapeutic issues in a man with symptomatic testosterone deficiency associated with the metabolic syndrome?
To read this article in its entirety, please visit our website.
-- Abdulmaged M. Traish, MBA, PhD, Martin M. Miner, MD, Abraham Morgentaler, MD, Michael Zitzmann, MD
This article originally appeared in the July 2011 issue of The American Journal of Medicine.
Abstract
Testosterone deficiency (TD) afflicts approximately 30% of men aged 40-79 years, with an increase in prevalence strongly associated with aging and common medical conditions including obesity, diabetes, and hypertension. A strong relationship is noted between TD and metabolic syndrome, although the relationship is not certain to be causal. Repletion of testosterone (T) in T-deficient men with these comorbidities may indeed reverse or delay their progression. While T repletion has been largely thought of in a sexual realm, we discuss its potential role in general men's health concerns: metabolic, body composition, and all-cause mortality through the use of a single clinical vignette. This review examines a host of studies, with practical recommendations for diagnosis of TD and T repletion in middle-aged and older men, including an analysis of treatment modalities and areas of concerns and uncertainty.
Case Study Example
A 52-year-old man of Caucasian descent presented with erectile dysfunction (ED), diminished libido, and fatigue. He took no medications and was otherwise healthy. He was 5 feet, 7 inches tall (170 cm) and weighed 217 pounds (98 kg), with a body mass index of 34 kg/m2 and a waist circumference of 43 inches (109.2 cm). His blood pressure was 135/80 mm Hg. Laboratory values were all normal except for serum total testosterone of 270 ng/dL (9.37 nmol/L) (normal reference range 300-1000 ng/dL [10.4-34.7 nmol/L]) and fasting serum glucose of 110 mg/dL (6.1mmol/L) (normal 67-99 mg/dL [3.7-5.5mmol/L]), indicating a component of metabolic syndrome (MetS).1 What are the diagnostic, prognostic, and therapeutic issues in a man with symptomatic testosterone deficiency associated with the metabolic syndrome?
To read this article in its entirety, please visit our website.
-- Abdulmaged M. Traish, MBA, PhD, Martin M. Miner, MD, Abraham Morgentaler, MD, Michael Zitzmann, MD
This article originally appeared in the July 2011 issue of The American Journal of Medicine.
The 10 Things I Like Best About My Job
I love going to work each day. Many things make work a pleasure, while others are best described as “irritating.” In the end, the positive items far outweigh the negative ones. This editorial will outline the 10 things that make my work days pleasant but, unlike the Letterman list, ranked in the order of their importance. Next month I will describe the 10 irritants that accompany my job. I would be happy to hear from others about the positive or negative events in their daily work routine.
Number 1: Personal interactions before, during, and after work with family members and friends. E-mail makes it possible to stay in touch with family and friends with rapid communications that do not interfere with the usually hectic work schedule.
Number 2: Because I work at a university hospital, I have contact throughout the day with young, enthusiastic, and knowledgeable students, residents, and fellows. Every one of these interactions, usually involving patient care but, at times, related to manuscript preparation, is a sheer delight. These contacts convince me that the next generation of physicians will grow and increase our profession's contributions to society in the future.
Number 3: I am often the attending physician of record on our coronary care unit, cardiology consult, and internal medicine ward services. It is no surprise that many of our patients are critically ill. The recovery of a patient whose life was in real jeopardy brings a moment of joy into my life and the lives of the trainees with whom I work.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD, editor-in-chief, The American Journal of Medicine
This article originally appeared in the August 2011 issue of The American Journal of Medicine.
Number 1: Personal interactions before, during, and after work with family members and friends. E-mail makes it possible to stay in touch with family and friends with rapid communications that do not interfere with the usually hectic work schedule.
Number 2: Because I work at a university hospital, I have contact throughout the day with young, enthusiastic, and knowledgeable students, residents, and fellows. Every one of these interactions, usually involving patient care but, at times, related to manuscript preparation, is a sheer delight. These contacts convince me that the next generation of physicians will grow and increase our profession's contributions to society in the future.
Number 3: I am often the attending physician of record on our coronary care unit, cardiology consult, and internal medicine ward services. It is no surprise that many of our patients are critically ill. The recovery of a patient whose life was in real jeopardy brings a moment of joy into my life and the lives of the trainees with whom I work.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD, editor-in-chief, The American Journal of Medicine
This article originally appeared in the August 2011 issue of The American Journal of Medicine.
Selasa, 26 Juli 2011
Chronic Pain Management: New interactive CME activities on AJM website
A new interactive continuing medical education (CME) activity with patient case videos has been posted on The American Journal of Medicine's website: Comprehensive Chronic Pain Management: Improving Physical and Psychological Function.
Here is the CME program description:
Here is the CME program description:
Using a unique, highly interactive, video patient case teaching format, this activity is intended to provide clinicians who manage patients with chronic pain with new insights and expand their understanding to achieve the goals of effective pain management -- reduction of pain, improvement in function, and restoration of psychological health-- utilizing a multidisciplinary (pharmacological and nonpharmacological) approach. Participants will have multiple “interactive” opportunities to reinforce their own best practices or recognize potential gaps in their clinical practice and will receive information to help them accurately assess the severity of pain, evaluate biopsychosocial factors that impact treatment, and develop strategies to meet the goals of therapy and improve patient outcomes.Click here to register and find out more about the program
This CME activity was originally presented on Saturday, March 26, 2011, in National Harbor, Maryland, and was adapted for release on July 21, 2011. Content was developed by faculty. The symposium was supported by an educational grant from PriCara, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc., administered by Ortho-McNeil Janssen Scientific Affairs, LLC.
The symposium was an official independent satellite symposium held in conjunction with the American Academy of Pain Medicine’s 27th Annual Meeting.
Jumat, 22 Juli 2011
An Unusual Complication of Crack Abuse
Blog Feature
Crack cocaine abuse is highly prevalent in the United States. Though physical withdrawal occurs rarely, the compulsion to smoke crack is powerful. In this case, a patient attempted to smoke crack through her tracheostomy and aspirated her glass crack pipe.
Case Report: A 50 year-old woman presented to the Emergency Department (ED) complaining of dyspnea for two hours. She had a history of laryngeal cancer and tracheostomy several years prior but because of longstanding discomfort at the tracheostomy site, she did not have a tracheostomy tube in place. She had a history of polysubstance abuse and was enrolled in a drug treatment program where she received methadone and psychosocial support. Urine toxicology reports at the program were intermittently positive for cocaine. In the ED she reported that an object had fallen into her tracheostomy. On physical examination the patient was tachypneic and agitated. Her lungs were clear to auscultation. Her oxygen saturation was 78% on room air. Chest radiography revealed a tubular radiodensity overlying the region of the carina and right mainstem bronchus. Bronchoscopy was performed urgently and a glass tube 3.2 cm in length was removed from the right mainstem bronchus. The tube was the size and shape of a pipe used to smoke crack cocaine [circled in the above image]. Copious secretions had accumulated behind the obstruction, but no injury to the airways was observed. The patient recovered uneventfully and continued intermittent crack abuse until just prior to her death three years later. She died due to a recurrence of her laryngeal cancer.
Discussion
Cocaine, including crack, is the second most commonly abused non-prescription illicit drug with 1.9 million Americans reporting use in the past month (1). Cocaine is associated with more emergency department visits than any other illicit drug (2). Cocaine abuse can lead dysfunction of multiple organ systems. For example, injecting cocaine can lead to skin and soft tissue infections as well as transmission of viral hepatitis and HIV. Smoking crack increases risk of pulmonary infections and chronic pulmonary disease. By any route, cocaine can cause myocardial infarction, cardiac arrhythmia and seizure.
Cocaine is highly addictive. Few psychosocial interventions have proved effective in treating cocaine abuse. Though multiple medications have been tried, none have proved effective in treating cocaine abuse in randomized controlled trials Cocaine vaccine is currently being investigated as a tool to prevent relapse among prior cocaine users.
Amongst poor urban populations, cocaine is most frequently smoked in the form of crack, the least expensive form of cocaine. Crack is commonly smoked from a glass pipe (“stem”) with a steel wool filter. Oral injuries such as burns and lacerations are common among crack abusers and can be routes of viral infection when smoking paraphernalia is shared. Tracheal and esophageal aspiration of smoking paraphernalia are rare sequelae of crack abuse. Published reports include cases of aspiration of bagged cocaine by a “body packer” (3), aspiration and ingestion of a steel wool filter (4) and ingestion of a crack pipe (5).
This unusual case graphically illustrates the tremendous compulsion to smoke crack, even in the face of extreme risk. Given the morbidity associated with cocaine abuse, efforts to prevent cocaine abuse as well as identify and treat patients who abuse cocaine are warranted.
-- Melissa Stein, MD
Albert Einstein College of Medicine/Montefiore Medical Center
References
1. Substance Abuse and Mental Health Services Administration. (2008). Results from the 2007 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-34, DHHS Publication No. SMA 08-4343). Rockville, MD.
2. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Drug Abuse Warning Network,2007: National Estimates of Drug-Related Emergency Department Visits. Rockville, MD, 2010.
3. Cobaugh DJ, Schneider SM, Benitez JG, Donahoe MP. Cocaine balloon aspiration: successful removal with bronchoscopy. Am J Emerg Med. 1997; 15(5):544-6.
4. Moettus A, Tandberg. Brillo crack pad aspiration and ingestion. J Emerg Med. 1998; 16(6):861-3.
5. Young J, Beech D, Offodile R. Foreign body ingestion and management: “I swallowed a crack pipe”. Am Surg. 2007; 73(11):1144-6.
Crack cocaine abuse is highly prevalent in the United States. Though physical withdrawal occurs rarely, the compulsion to smoke crack is powerful. In this case, a patient attempted to smoke crack through her tracheostomy and aspirated her glass crack pipe.
Case Report: A 50 year-old woman presented to the Emergency Department (ED) complaining of dyspnea for two hours. She had a history of laryngeal cancer and tracheostomy several years prior but because of longstanding discomfort at the tracheostomy site, she did not have a tracheostomy tube in place. She had a history of polysubstance abuse and was enrolled in a drug treatment program where she received methadone and psychosocial support. Urine toxicology reports at the program were intermittently positive for cocaine. In the ED she reported that an object had fallen into her tracheostomy. On physical examination the patient was tachypneic and agitated. Her lungs were clear to auscultation. Her oxygen saturation was 78% on room air. Chest radiography revealed a tubular radiodensity overlying the region of the carina and right mainstem bronchus. Bronchoscopy was performed urgently and a glass tube 3.2 cm in length was removed from the right mainstem bronchus. The tube was the size and shape of a pipe used to smoke crack cocaine [circled in the above image]. Copious secretions had accumulated behind the obstruction, but no injury to the airways was observed. The patient recovered uneventfully and continued intermittent crack abuse until just prior to her death three years later. She died due to a recurrence of her laryngeal cancer.
Discussion
Cocaine, including crack, is the second most commonly abused non-prescription illicit drug with 1.9 million Americans reporting use in the past month (1). Cocaine is associated with more emergency department visits than any other illicit drug (2). Cocaine abuse can lead dysfunction of multiple organ systems. For example, injecting cocaine can lead to skin and soft tissue infections as well as transmission of viral hepatitis and HIV. Smoking crack increases risk of pulmonary infections and chronic pulmonary disease. By any route, cocaine can cause myocardial infarction, cardiac arrhythmia and seizure.
Cocaine is highly addictive. Few psychosocial interventions have proved effective in treating cocaine abuse. Though multiple medications have been tried, none have proved effective in treating cocaine abuse in randomized controlled trials Cocaine vaccine is currently being investigated as a tool to prevent relapse among prior cocaine users.
Amongst poor urban populations, cocaine is most frequently smoked in the form of crack, the least expensive form of cocaine. Crack is commonly smoked from a glass pipe (“stem”) with a steel wool filter. Oral injuries such as burns and lacerations are common among crack abusers and can be routes of viral infection when smoking paraphernalia is shared. Tracheal and esophageal aspiration of smoking paraphernalia are rare sequelae of crack abuse. Published reports include cases of aspiration of bagged cocaine by a “body packer” (3), aspiration and ingestion of a steel wool filter (4) and ingestion of a crack pipe (5).
This unusual case graphically illustrates the tremendous compulsion to smoke crack, even in the face of extreme risk. Given the morbidity associated with cocaine abuse, efforts to prevent cocaine abuse as well as identify and treat patients who abuse cocaine are warranted.
-- Melissa Stein, MD
Albert Einstein College of Medicine/Montefiore Medical Center
References
1. Substance Abuse and Mental Health Services Administration. (2008). Results from the 2007 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-34, DHHS Publication No. SMA 08-4343). Rockville, MD.
2. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Drug Abuse Warning Network,2007: National Estimates of Drug-Related Emergency Department Visits. Rockville, MD, 2010.
3. Cobaugh DJ, Schneider SM, Benitez JG, Donahoe MP. Cocaine balloon aspiration: successful removal with bronchoscopy. Am J Emerg Med. 1997; 15(5):544-6.
4. Moettus A, Tandberg. Brillo crack pad aspiration and ingestion. J Emerg Med. 1998; 16(6):861-3.
5. Young J, Beech D, Offodile R. Foreign body ingestion and management: “I swallowed a crack pipe”. Am Surg. 2007; 73(11):1144-6.
Rabu, 20 Juli 2011
AJM Editor-in-Chief previews the August issue (video)
What new research will be included in the August 2011 issue of The American Journal of Medicine, check out this video clip with Dr. Joseph S. Alpert, editor-in-chief.
Selasa, 19 Juli 2011
Treating Patients High on Bath Salts: A Growing Problem
Emergency rooms and poison control centers across the country are seeing increasing numbers of people high on bath salts. Yes... bath salts.
Sold legally in head shops and convenience stores, the bath salts are advertised as a bathing product, but people are snorting, injecting, or smoking them to get high. The problem is that users can become psychotic, violent, and dangerous to themselves and others under the influence of bath salts. Further compounding the problem, doctors are not clear how to treat these patients when they arrive in the emergency rooms, the compounds may not show up on drug screening tests, and the negative effects can be long-lasting. Ingesting bath salts is very dangerous.
Recently, the New York Times published a story about the bath salts, which are legal in many states. According to the Times, between January and June 2011, there were 3,470 calls to poison control centers about bath salts-- up from 303 calls in 2010.
On The American Journal of Medicine website, the case study Bath Salts as a "Legal High" appears as an article in press. From the article by Smith et al...
The full story can be found here.
Sold legally in head shops and convenience stores, the bath salts are advertised as a bathing product, but people are snorting, injecting, or smoking them to get high. The problem is that users can become psychotic, violent, and dangerous to themselves and others under the influence of bath salts. Further compounding the problem, doctors are not clear how to treat these patients when they arrive in the emergency rooms, the compounds may not show up on drug screening tests, and the negative effects can be long-lasting. Ingesting bath salts is very dangerous.
Recently, the New York Times published a story about the bath salts, which are legal in many states. According to the Times, between January and June 2011, there were 3,470 calls to poison control centers about bath salts-- up from 303 calls in 2010.
On The American Journal of Medicine website, the case study Bath Salts as a "Legal High" appears as an article in press. From the article by Smith et al...
Abuse of bath salts is a new trend in the US for those trying to obtain “legal highs.” A study in the United Kingdom found 1308 products for sale, in the form of pills, smoking materials, and single plant material/extracts.(1)
Our case illustrates the clinical presentation after using bath salts as a “legal high.” Drug screens will usually be negative, and poison control centers may not have knowledge of these compounds. Internet sites listed components of “Cristalius” to include: creatine, caffeine, “herbal blends,” hoodia, and sodium sesquicarbonate (the bath salt component). These products are advertised for bathing and not for human consumption and are found by many names, including “Ivory Wave,” “Vanilla Sky,” “Snow,” and “Hurricane Charlie.” The drugs are usually snorted, but may be ingested, injected, or smoked. (2, 3)
The full story can be found here.
Kamis, 14 Juli 2011
Effect of Aspirin on Mortality in the Primary Prevention of Cardiovascular Disease
In patients without a history of cardiovascular disease, aspirin prevents deaths as well as myocardial infarction and ischemic stroke but increases hemorrhagic stroke and major bleeding when used in primary prevention of cardiovascular disease.
Abstract
Objective
The lack of a mortality benefit of aspirin in prior meta-analyses of primary prevention trials of cardiovascular disease has contributed to uncertainty about the balance of benefits and risks of aspirin in primary prevention. We performed an updated meta-analysis of randomized controlled trials of aspirin to obtain best estimates of the effect of aspirin on mortality in primary prevention.
Methods
Eligible articles were identified by searches of electronic databases and reference lists. Outcomes of interest were all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, and bleeding. Data were pooled from individual trials using the DerSimonian-Laird random-effects model, and results are presented as relative risk (RR) and 95% confidence intervals (CIs).
Results
Nine randomized controlled trials enrolling 100,076 participants were included. Aspirin reduced all-cause mortality (RR 0.94; 95% CI, 0.88-1.00), myocardial infarction (RR 0.83; 95% CI, 0.69-1.00), ischemic stroke (RR 0.86; 95% CI, 0.75-0.98), and the composite of myocardial infarction, stroke, or cardiovascular death (RR 0.88; 95% CI, 0.83-0.94), but did not reduce cardiovascular mortality (RR 0.96; 95% CI, 0.84-1.09). Aspirin increased the risk of hemorrhagic stroke (RR 1.36; 95% CI, 1.01-1.82), major bleeding (RR 1.66; 95% CI, 1.41-1.95), and gastrointestinal bleeding (RR 1.37; 95% CI, 1.15-1.62). A lack of availability of patient-level data precluded exploration of benefits and risks of aspirin in key subgroups.
Conclusion
Aspirin prevents deaths, myocardial infarction, and ischemic stroke, and increases hemorrhagic stroke and major bleeding when used in the primary prevention of cardiovascular disease.
To read this article in its entirety, please visit our website.
-- Nina Raju, MD, MsC, Magdalena Sobieraj-Teague, MBBS, Jack Hirsh, MD, Martin O'Donnell, MD, PhD, John Eikelboom, MD, MsC
This article originally appeared in the July 2011 issue of The American Journal of Medicine.
Abstract
Objective
The lack of a mortality benefit of aspirin in prior meta-analyses of primary prevention trials of cardiovascular disease has contributed to uncertainty about the balance of benefits and risks of aspirin in primary prevention. We performed an updated meta-analysis of randomized controlled trials of aspirin to obtain best estimates of the effect of aspirin on mortality in primary prevention.
Methods
Eligible articles were identified by searches of electronic databases and reference lists. Outcomes of interest were all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, and bleeding. Data were pooled from individual trials using the DerSimonian-Laird random-effects model, and results are presented as relative risk (RR) and 95% confidence intervals (CIs).
Results
Nine randomized controlled trials enrolling 100,076 participants were included. Aspirin reduced all-cause mortality (RR 0.94; 95% CI, 0.88-1.00), myocardial infarction (RR 0.83; 95% CI, 0.69-1.00), ischemic stroke (RR 0.86; 95% CI, 0.75-0.98), and the composite of myocardial infarction, stroke, or cardiovascular death (RR 0.88; 95% CI, 0.83-0.94), but did not reduce cardiovascular mortality (RR 0.96; 95% CI, 0.84-1.09). Aspirin increased the risk of hemorrhagic stroke (RR 1.36; 95% CI, 1.01-1.82), major bleeding (RR 1.66; 95% CI, 1.41-1.95), and gastrointestinal bleeding (RR 1.37; 95% CI, 1.15-1.62). A lack of availability of patient-level data precluded exploration of benefits and risks of aspirin in key subgroups.
Conclusion
Aspirin prevents deaths, myocardial infarction, and ischemic stroke, and increases hemorrhagic stroke and major bleeding when used in the primary prevention of cardiovascular disease.
To read this article in its entirety, please visit our website.
-- Nina Raju, MD, MsC, Magdalena Sobieraj-Teague, MBBS, Jack Hirsh, MD, Martin O'Donnell, MD, PhD, John Eikelboom, MD, MsC
This article originally appeared in the July 2011 issue of The American Journal of Medicine.
Selasa, 12 Juli 2011
The DRESS Syndrome: A Literature Review
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a potential life-threatening syndrome including severe eruption, fever, hypereosinophilia and internal organ involvement. Although 50 drugs can induce DRESS, the main culprit drugs are carbamazepine and allopurinol.
Abstract
The Drug Reaction with Eosinophilia and Systemic Symptom (DRESS) is a severe adverse drug-induced reaction. Diagnosing DRESS is challenging due to the diversity of cutaneous eruption and organs involved. We used the RegiSCAR scoring system that grades DRESS cases as “no,” “possible,” “probable,” or “definite” to classify cases reported in the literature. We also analyzed the clinical course and treatments of the cases. A total of 44 drugs were associated with the 172 cases reported between January 1997 and May 2009 in PubMed and MEDLINE. The most frequently reported drug was carbamazepine, and the vast majority of cases were classified as “probable/definite” DRESS cases. Hypereosinophilia, liver involvement, fever, and lymphadenopathy were significantly associated with “probable/definite” DRESS cases, whereas skin rash was described in almost all of the cases, including “possible cases.” Culprit drug withdrawal and corticosteroids constituted the mainstay of DRESS treatment. The outcome was death in 9 cases. However, no predictive factors for serious cases were found. This better knowledge of DRESS may contribute to improve the diagnosis and management of this syndrome in clinical practice.
To read this article in its entirety, please visit our website.
-- Patrice Cacoub, MD, PhD, Philippe Musette, MD, PhD, Vincent Descamps, MD, PhD, Olivier Meyer, MD, PhD, Chris Speirs, MD, Laetitia Finzi, MD, PhD, Jean Claude Roujeau, MD
This article originally appeared in the July 2011 issue of The American Journal of Medicine.
Abstract
The Drug Reaction with Eosinophilia and Systemic Symptom (DRESS) is a severe adverse drug-induced reaction. Diagnosing DRESS is challenging due to the diversity of cutaneous eruption and organs involved. We used the RegiSCAR scoring system that grades DRESS cases as “no,” “possible,” “probable,” or “definite” to classify cases reported in the literature. We also analyzed the clinical course and treatments of the cases. A total of 44 drugs were associated with the 172 cases reported between January 1997 and May 2009 in PubMed and MEDLINE. The most frequently reported drug was carbamazepine, and the vast majority of cases were classified as “probable/definite” DRESS cases. Hypereosinophilia, liver involvement, fever, and lymphadenopathy were significantly associated with “probable/definite” DRESS cases, whereas skin rash was described in almost all of the cases, including “possible cases.” Culprit drug withdrawal and corticosteroids constituted the mainstay of DRESS treatment. The outcome was death in 9 cases. However, no predictive factors for serious cases were found. This better knowledge of DRESS may contribute to improve the diagnosis and management of this syndrome in clinical practice.
To read this article in its entirety, please visit our website.
-- Patrice Cacoub, MD, PhD, Philippe Musette, MD, PhD, Vincent Descamps, MD, PhD, Olivier Meyer, MD, PhD, Chris Speirs, MD, Laetitia Finzi, MD, PhD, Jean Claude Roujeau, MD
This article originally appeared in the July 2011 issue of The American Journal of Medicine.
Senin, 11 Juli 2011
Should the Affordable Care Act of 2010 Be Repealed? Another viewpoint from an AJM reader
Blog Commentary
In the July 2011 issue, The American Journal of Medicine published Should the Affordable Care Act of 2010 Be Repealed? by James E. Dalen, MD, MPH, AJM associate editor and Dean Emeritus of the University of Arizona College of Medicine, in the Journal and on this blog. AJM has received several e-mails and a few phone calls (pro and con) related to this article. Here is one commentary that takes issue with Dalen's commentary supporting the Affordable Care Act.
Should the Affordable Care Act of 2010 Be Repealed? A Fuller Picture
Dr. Dalen’s commentary in the July 2011(1) issue simply repeats the longstanding arguments supporting the Patient Protection and Affordable Care Act (PPACA), without shedding any new light on it since its passage in March of 2010. I take issue with his one-sided view of the law and its subsequent impact, and supply responses to contentions while describing some underpinnings of the opposition.
The Politics of Passage
Table 1 (below) delineates the votes of the health care bill, beginning with the initial version crafted from three House committees and passed on November 7, 2009.(2) Then, on December 24, 2009, the Senate passed its version on a party-line vote.(3) Because the Senate bill differed from that of the House, it needed to return there for ultimate approval. After much politicking, and the inability to alter anything, it was ultimately brought to the floor late Sunday evening on March 21, 2010, and narrowly saved the President from scathing defeat.(4) Table 1 also shows Medicare’s passage for comparison.(5)
After claiming that Americans would watch the health care debate occur on C-SPAN, in the most transparent government, President Obama failed to deliver on either. Most Americans did not envision back-room deals tantamount to bribery to secure votes, or accounting gimmicks to seemingly keep the price tag below the $1 trillion ceiling. They did not expect to hear Nancy Pelosi (D-CA) tell them that they needed to pass it to find out what was in it 6 or have no time to actually digest the monstrosity before rendering a well-read opinion. And they certainly did not expect a vote on an issue that consumes nearly 20% of our GDP to occur in such a clearly partisan fashion on Christmas Eve or late one Sunday night. The ends do not justify the means.
The World’s Best Health Care System
The commentary resurrects the issue of health outcomes by solely touting those statistics that satisfy the author’s premise. Some noteworthy others – according to the WHO’s 2010 World Health Statistics, the USA ranks as the 3rd lowest (best) country in those under age 5 who are underweight. To immunization rates, the Americas have the lowest incidence of measles and mumps in the world, a significantly higher percentage of neonates protected at birth against neonatal tetanus compared to our European colleagues, and the highest rates of hepatitis B vaccination among 1-year olds in the world. Further, according to the Organization for Economic Co-operation and Development (OECD) Health Care Quality Indicators Project, the US has the highest five-year relative survival rates in the world for breast cancer, and the third highest rate for colorectal cancer.(7)
The Americas have 23 physicians and 55 nursing and midwifery personnel per 10,000 population compared to 33 and 68, respectively, for the European region. Perhaps some statistics touted by others as better are simply a result of a larger healthcare workforce, thereby increasing access to care.(8)
The Uninsured
Dr. Dalen writes “22% of our citizens were uninsured or had inadequate health insurance in 2007,” and then lists “50+ million uninsured Americans” in table 3. Not all uninsured people in this country are in-fact American, or even legal residents. According to 2005 census data, 45.8 million people were uninsured. While non-citizens represented 7% of the population, they accounted for 21% of this group, or more than 9.5M individuals. Further, 20% (9.16M) were uninsured for less than 3 months. And, 28% (12.8M) were above 300% of the federal poverty line (FPL). [Federal Poverty Level chart] At that level, single coverage premiums would account for 2% of annual income and premiums for a family of four would amount to 4.7%. This leaves a legitimate number of 14.2M US citizens making less than 300% of the FPL who were uninsured for more than 3 months – 5% of all US inhabitants.(9)
In the description of table 3, it states that “all uninsured Americans will certainly benefit by receiving coverage.” Yet under the section on ACA and the uninsured, the figure is “95% of legal US residents…” Based on a population of 300 million, this 5% disparity accounts for some 15 million people and does not satisfy the claim of insuring everyone, as originally billed in the run-up to the bill’s final passage.
Does Coverage Equal Access?
Dr. Dalen claims that by expanding coverage to the uninsured, “the US would finally…[ensure] that nearly all of its citizens have access to health care.” He makes the colossal mistake of equating coverage to access. The nation’s current physician shortage already results in delays to access. Add to this some 30 million newly-insured patients, and the delay simply becomes longer. Coverage does not equal access. Just look at Massachusetts.(10, 11)
The Devil is in the Details
The paper purports that nearly everyone stands to benefit from the government’s attempt at healthcare overhaul. It conveniently neglects to highlight what needs to be replaced, or simply repealed. (1) The 1099 tax reporting requirement under PPACA for all vendors receiving more the $600 was repealed earlier this year. (2) CMS recently disseminated its proposed rule regarding accountable care organizations (ACOs). When most of the institutions it touted as successful examples publicly stated their resistance, CMS promulgated new rules to entice participation. Still far from making any significant impact on the nation’s healthcare expenditures, ACOs will not likely meet their January 1, 2012 implementation target date because of inherent design flaws. (3) The independent payment advisory board (IPAB) is being attacked at present with bills in both houses of Congress calling for repeal. In bipartisan fashion, it appears likely that this will be eliminated. (4) Above all else is the individual mandate, currently under legal attack. The Supreme Court will rule on its constitutionality.
There appear to be aspects of the law that may benefit patients, namely insurance industry reforms. But these come at a cost, one that will certainly be borne by those insured in the nature of higher premiums.
While obvious is the massive expansion of entitlement programs (read government takeover), glaringly missing from PPACA is meaningful tort reform and a fix to the sustainable growth rate (SGR). Physicians who care for Medicare beneficiaries continue to be shackled to this failed reimbursement calculation. Faced with a nearly 30% cut in reimbursement rates on January 1, 2012, some physicians have stopped accepting Medicare patients, while others have opted to retire early or leave medicine altogether because they cannot run their business under the constant threat of disastrous cuts. Combine the increased number of newly-insured patients clamoring for access, the growth of the baby boomer population, and a decreasing supply of physicians, and a perfect storm is brewing leading to an incredible gap between supply and demand.
The PPACA should be repealed and replaced with a real attempt at addressing our nation’s issues, without exceptions for unions, bribes for lawmakers, or back-room deals in the middle of the night in a strictly partisan fashion. The Democrats had a golden opportunity to put everything on the table, but squandered it to save face for the President. This came at a price, one that was only partially paid in November of 2010, but whose debt will be fulfilled next November.
-- Joshua D. Lenchus, DO, RPh
University of Miami Miller School of Medicine
References
1. Dalen JE. Should the affordable care act of 2010 be repealed? Am J Med. 2011;124(7):575-577.
2. H.R.3962 – Affordable Health Care for America Act. Available at: http://www.opencongress.org/bill/111-h3962/show. Accessed June 21, 2011.
3. H.R.3590 – Patient Protection and Affordable Care Act. Available at: http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=111&session=1&vote=00396#position. Accessed June 21, 2011.
4. H.R.3590 – Patient Protection and Affordable Care Act. Available at: http://clerk.house.gov/evs/2010/roll165.xml. Accessed June 21, 2011.
5. H.R.6675 – The Social Security Amendments of 1965. Available at: http://www.ssa.gov/history/tally65.html. Accessed June 21, 2011.
6. Roff P. Pelosi: Pass Health Reform So You Can Find Out What’s In It. US News and World Report, March 9, 2010. Available at: http://www.usnews.com/opinion/blogs/peter-roff/2010/03/09/pelosi-pass-health-reform-so-you-can-find-out-whats-in-it. Accessed June 23, 2011.
7. Organisation for Economic Co-operation and Development (OECD). Health care quality indicators. Available at: http://www.oecd.org/document/34/0,3746,en_2649_37407_37088930_1_1_1_37407,00.html. Accessed June 22, 2011.
8. World Health Organization (WHO). World health statistics 2010. Available at: http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf. Accessed June 21, 2011.
9. U.S. Department of Health and Human Services. Overview of the uninsured in the United States: An analysis of the 2007 current population survey. Available at: http://aspe.hhs.gov/health/reports/07/uninsured/report.pdf. Accessed June 22, 2011.
10. Access to Massachusetts health care still tight. GazetteNet.com, Daily Hampshire Gazette. 2010 Nov 16. Available at: http://www.gazettenet.com/2010/11/16/report-health-access-still-tight. Accessed June 22, 2011.
11. Massachusetts Medical Society. 2011 Patient access to health care study: A survey of Massachusetts physicians’ offices. Available at: http://www.massmed.org/AM/Template.cfm?Section=Research_Reports_and_Studies2&CONTENTID=54336&TEMPLATE=/CM/ContentDisplay.cfm. Accessed June 22, 2011.
In the July 2011 issue, The American Journal of Medicine published Should the Affordable Care Act of 2010 Be Repealed? by James E. Dalen, MD, MPH, AJM associate editor and Dean Emeritus of the University of Arizona College of Medicine, in the Journal and on this blog. AJM has received several e-mails and a few phone calls (pro and con) related to this article. Here is one commentary that takes issue with Dalen's commentary supporting the Affordable Care Act.
Should the Affordable Care Act of 2010 Be Repealed? A Fuller Picture
Dr. Dalen’s commentary in the July 2011(1) issue simply repeats the longstanding arguments supporting the Patient Protection and Affordable Care Act (PPACA), without shedding any new light on it since its passage in March of 2010. I take issue with his one-sided view of the law and its subsequent impact, and supply responses to contentions while describing some underpinnings of the opposition.
The Politics of Passage
Table 1 (below) delineates the votes of the health care bill, beginning with the initial version crafted from three House committees and passed on November 7, 2009.(2) Then, on December 24, 2009, the Senate passed its version on a party-line vote.(3) Because the Senate bill differed from that of the House, it needed to return there for ultimate approval. After much politicking, and the inability to alter anything, it was ultimately brought to the floor late Sunday evening on March 21, 2010, and narrowly saved the President from scathing defeat.(4) Table 1 also shows Medicare’s passage for comparison.(5)
After claiming that Americans would watch the health care debate occur on C-SPAN, in the most transparent government, President Obama failed to deliver on either. Most Americans did not envision back-room deals tantamount to bribery to secure votes, or accounting gimmicks to seemingly keep the price tag below the $1 trillion ceiling. They did not expect to hear Nancy Pelosi (D-CA) tell them that they needed to pass it to find out what was in it 6 or have no time to actually digest the monstrosity before rendering a well-read opinion. And they certainly did not expect a vote on an issue that consumes nearly 20% of our GDP to occur in such a clearly partisan fashion on Christmas Eve or late one Sunday night. The ends do not justify the means.
The World’s Best Health Care System
The commentary resurrects the issue of health outcomes by solely touting those statistics that satisfy the author’s premise. Some noteworthy others – according to the WHO’s 2010 World Health Statistics, the USA ranks as the 3rd lowest (best) country in those under age 5 who are underweight. To immunization rates, the Americas have the lowest incidence of measles and mumps in the world, a significantly higher percentage of neonates protected at birth against neonatal tetanus compared to our European colleagues, and the highest rates of hepatitis B vaccination among 1-year olds in the world. Further, according to the Organization for Economic Co-operation and Development (OECD) Health Care Quality Indicators Project, the US has the highest five-year relative survival rates in the world for breast cancer, and the third highest rate for colorectal cancer.(7)
The Americas have 23 physicians and 55 nursing and midwifery personnel per 10,000 population compared to 33 and 68, respectively, for the European region. Perhaps some statistics touted by others as better are simply a result of a larger healthcare workforce, thereby increasing access to care.(8)
The Uninsured
Dr. Dalen writes “22% of our citizens were uninsured or had inadequate health insurance in 2007,” and then lists “50+ million uninsured Americans” in table 3. Not all uninsured people in this country are in-fact American, or even legal residents. According to 2005 census data, 45.8 million people were uninsured. While non-citizens represented 7% of the population, they accounted for 21% of this group, or more than 9.5M individuals. Further, 20% (9.16M) were uninsured for less than 3 months. And, 28% (12.8M) were above 300% of the federal poverty line (FPL). [Federal Poverty Level chart] At that level, single coverage premiums would account for 2% of annual income and premiums for a family of four would amount to 4.7%. This leaves a legitimate number of 14.2M US citizens making less than 300% of the FPL who were uninsured for more than 3 months – 5% of all US inhabitants.(9)
In the description of table 3, it states that “all uninsured Americans will certainly benefit by receiving coverage.” Yet under the section on ACA and the uninsured, the figure is “95% of legal US residents…” Based on a population of 300 million, this 5% disparity accounts for some 15 million people and does not satisfy the claim of insuring everyone, as originally billed in the run-up to the bill’s final passage.
Does Coverage Equal Access?
Dr. Dalen claims that by expanding coverage to the uninsured, “the US would finally…[ensure] that nearly all of its citizens have access to health care.” He makes the colossal mistake of equating coverage to access. The nation’s current physician shortage already results in delays to access. Add to this some 30 million newly-insured patients, and the delay simply becomes longer. Coverage does not equal access. Just look at Massachusetts.(10, 11)
The Devil is in the Details
The paper purports that nearly everyone stands to benefit from the government’s attempt at healthcare overhaul. It conveniently neglects to highlight what needs to be replaced, or simply repealed. (1) The 1099 tax reporting requirement under PPACA for all vendors receiving more the $600 was repealed earlier this year. (2) CMS recently disseminated its proposed rule regarding accountable care organizations (ACOs). When most of the institutions it touted as successful examples publicly stated their resistance, CMS promulgated new rules to entice participation. Still far from making any significant impact on the nation’s healthcare expenditures, ACOs will not likely meet their January 1, 2012 implementation target date because of inherent design flaws. (3) The independent payment advisory board (IPAB) is being attacked at present with bills in both houses of Congress calling for repeal. In bipartisan fashion, it appears likely that this will be eliminated. (4) Above all else is the individual mandate, currently under legal attack. The Supreme Court will rule on its constitutionality.
There appear to be aspects of the law that may benefit patients, namely insurance industry reforms. But these come at a cost, one that will certainly be borne by those insured in the nature of higher premiums.
While obvious is the massive expansion of entitlement programs (read government takeover), glaringly missing from PPACA is meaningful tort reform and a fix to the sustainable growth rate (SGR). Physicians who care for Medicare beneficiaries continue to be shackled to this failed reimbursement calculation. Faced with a nearly 30% cut in reimbursement rates on January 1, 2012, some physicians have stopped accepting Medicare patients, while others have opted to retire early or leave medicine altogether because they cannot run their business under the constant threat of disastrous cuts. Combine the increased number of newly-insured patients clamoring for access, the growth of the baby boomer population, and a decreasing supply of physicians, and a perfect storm is brewing leading to an incredible gap between supply and demand.
The PPACA should be repealed and replaced with a real attempt at addressing our nation’s issues, without exceptions for unions, bribes for lawmakers, or back-room deals in the middle of the night in a strictly partisan fashion. The Democrats had a golden opportunity to put everything on the table, but squandered it to save face for the President. This came at a price, one that was only partially paid in November of 2010, but whose debt will be fulfilled next November.
-- Joshua D. Lenchus, DO, RPh
University of Miami Miller School of Medicine
References
1. Dalen JE. Should the affordable care act of 2010 be repealed? Am J Med. 2011;124(7):575-577.
2. H.R.3962 – Affordable Health Care for America Act. Available at: http://www.opencongress.org/bill/111-h3962/show. Accessed June 21, 2011.
3. H.R.3590 – Patient Protection and Affordable Care Act. Available at: http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=111&session=1&vote=00396#position. Accessed June 21, 2011.
4. H.R.3590 – Patient Protection and Affordable Care Act. Available at: http://clerk.house.gov/evs/2010/roll165.xml. Accessed June 21, 2011.
5. H.R.6675 – The Social Security Amendments of 1965. Available at: http://www.ssa.gov/history/tally65.html. Accessed June 21, 2011.
6. Roff P. Pelosi: Pass Health Reform So You Can Find Out What’s In It. US News and World Report, March 9, 2010. Available at: http://www.usnews.com/opinion/blogs/peter-roff/2010/03/09/pelosi-pass-health-reform-so-you-can-find-out-whats-in-it. Accessed June 23, 2011.
7. Organisation for Economic Co-operation and Development (OECD). Health care quality indicators. Available at: http://www.oecd.org/document/34/0,3746,en_2649_37407_37088930_1_1_1_37407,00.html. Accessed June 22, 2011.
8. World Health Organization (WHO). World health statistics 2010. Available at: http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf. Accessed June 21, 2011.
9. U.S. Department of Health and Human Services. Overview of the uninsured in the United States: An analysis of the 2007 current population survey. Available at: http://aspe.hhs.gov/health/reports/07/uninsured/report.pdf. Accessed June 22, 2011.
10. Access to Massachusetts health care still tight. GazetteNet.com, Daily Hampshire Gazette. 2010 Nov 16. Available at: http://www.gazettenet.com/2010/11/16/report-health-access-still-tight. Accessed June 22, 2011.
11. Massachusetts Medical Society. 2011 Patient access to health care study: A survey of Massachusetts physicians’ offices. Available at: http://www.massmed.org/AM/Template.cfm?Section=Research_Reports_and_Studies2&CONTENTID=54336&TEMPLATE=/CM/ContentDisplay.cfm. Accessed June 22, 2011.
Kamis, 07 Juli 2011
Better Health: Can Physical Exams Save Healthcare Costs?
The Better Health blog recently posted an interesting story about really seeing your patients during the physical exam: Can Physical Exams Save Healthcare Costs?
The American Journal of Medicine has published many research articles and commentaries about the art of physical examination. In addition, the Journal's Physical Findings section is a regular feature, which occurs several times a year. These articles focus on physical exam skills and specific physical traits that can give physicians significant clues regarding underlying disease. Here are links to some recent Physical Findings articles published by AJM.
Ludwig's Angina
Stop, You're Making Me Blush
Muehrcke's Lines
Nailing the Diagnosis!
For other Physical Findings articles, check out the Journal's website.
The American Journal of Medicine has published many research articles and commentaries about the art of physical examination. In addition, the Journal's Physical Findings section is a regular feature, which occurs several times a year. These articles focus on physical exam skills and specific physical traits that can give physicians significant clues regarding underlying disease. Here are links to some recent Physical Findings articles published by AJM.
Ludwig's Angina
Stop, You're Making Me Blush
Muehrcke's Lines
Nailing the Diagnosis!
For other Physical Findings articles, check out the Journal's website.
Selasa, 05 Juli 2011
Terry's Nails: A Window to Systemic Diseases
The American Journal of Medicine blog has moved to: http://amjmed.org.
You can read "Terry's Nails: A Window to Systemic Diseases" here: http://amjmed.org/terrys-nails-a-window-to-systemic-diseases/
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