Archive for the ‘physician initiatives’ Category

Medical Waste: Part one

Thursday, April 12th, 2012

health care costs are making news and setting records

Whenever I think of medical waste I flash back to the episode (It's in one of my old blog posts) with my Radiation Safety Officer standing on a pile of garbage in a municipal dump in Biloxi, MS, holding a Coke bottle that set off a radiation detector. It had tobacco juice spat by a patient who'd had a thyroid scan.

But that's not what I'm writing about today.

There's a great article in the most recent edition of JAMA with the title "Eliminating Waste in US Health Care."  In July, 2010, Dr. Donald Berwick, the lead author, was appointed by President Obama to serve as the Administrator of the Centers for Medicare and Medicaid Services. This was a "recess appointment" of a Harvard Medical School professor of pediatrics with a Master of Public Policy degree who had previously led the non-profit Institute for Healthcare Improvement. Congress did not confirm Berwick (ah, politics, isn't it wonderful) and he left  the position in December, 2011.

Berwick and a colleague at the RAND Corporation. a non-profit with goals of improving both decision-making and public policy by utilizing research and analysis, start by stating our health care costs are frankly not sustainable and yet are growing with 2020 estimates of 20% of our gross domestic product (GDP).

Between 1980 and 2008, our US health care costs, as a share of GDP grew phenomenally. The Kaiser Foundation has an online comparison of health care expenditures in the US and 14 other OECD countries. We not only spend more on health care, our per person growth rate of this expenditure is among the highest in the developed world. Let's put that into concrete terms. The Kaiser paper shows a graph of total health care spending per person versus gross domestic product per person and locates where 15 of the world's developed countries fall in comparing those two variables.

The dots representing thirteen of the countries form a line with Italy having the last spending and the least average "income" per person and Switzerland having the top amounts of that group in both categories. Then there's Norway and the United States, both well off the line. The average Norwegian income is considerably higher than the US average, but the average amount spend on all their health care is way below the line, while ours is far above that same line.

These were 2008 figures, but the major difference was shown in growth of the total spent on health care per person per year and the source of that money. In Norway's case, the bulk is public spending and in ours it is split between public and private. And our growth in both categories tops the pack.

It's time to look at all the ways to solve the puzzle

Dr. Berkwick's article in JAMA details how much we could potentially save with six strategies to reduce "medical waste." The total is staggering: $3 trillion in Medicare and Medicaid savings and $11 trillion overall by 2020. He contrasts this to the savings proposed in the Affordable Healthcare Act of $670 billion between 2011 and 2019, no paltry sum by any means, but dwarfed by the common sense proposals he makes.

And nobody loses by our taking a very close look at his concepts.

 

 

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Vindication? Part 1

Thursday, January 5th, 2012

One way to get lots of protein

Since the late 1990s when I invented a diet, or perhaps I should say an eating pattern, I've relied on one principal concept: Eat Less; Do More. I came upon this simple idea after listening to a group of medical professionals who were discussing which diet they should go on while they were simultaneously consuming huge portions at our hospital cafeteria.

One of them, I recalled, had tried a high-carb, low-protein diet the past year; losing nearly twenty pounds, then regained it all and more in a few months. Now she was going to attempt  to lose twenty-five pounds with a different approach, this one with an emphasis on protein. I had seen weight-loss plans come and go and didn't believe any of them were the answer, at least not for everyone. I remember coming home and saying to my wife, "Lynn, I've invented a new diet"

I explained it was simply, "Never finish anything; No snacks between (meals); Nothing after eight." I added, "Get lots of exercise."

I lost the seven pounds I had gained on a two-week vacation and didn't need my strategy again until early in 2009. Then I weighed 177 one morning, up three pounds from my normal weight since 1991. I attributed that to eating out four times in the prior week. But when I tried on a pair of good suit slacks, I realized the weight hadn't changed much, but the distribution sure had.

I went back to my eating plan, lost five pounds easily, then coasted a while before resuming the diet. Lynn bought me a digital scale and I weighed myself daily. I also started going to our gym six days a week. Eventually I shed thirty pounds and five inches off my waistline. At 147 pounds I was twenty-five under my usual high school weight. This morning, nearly two years later, I weighed 148.

I allow myself a three-pound zone of weight fluctuation, thinking that would account for fluid shifts and the occasional big splurge. Whenever I exceed 150 pounds I go back on my plan.

Then I read a Wall Street Journal article titled "New Ways Calories Can Add Up to Weight Gain: Study Challenges Idea That Varying Amounts Of Fat, Protein and Carbohydrates Are Key to Weight Loss." It quoted the Journal of the American Medical Association, AKA: JAMA. I went online and found the JAMA article and an accompanying editorial.

I read both pieces in detail, even finding a wild typo, "...their diets were returned to baseline energy levels and diet compositions (15% from protein, 35% from fat and 60% from carbohydrate)." I called the AMA and suggested they correct the numbers since they added to 110%.

Is a high-carb, low-protein diet safer?

But the basic premise of the study's data intrigued me. It's something I've believed for years, calories count, as opposed to what form those calories come in. But there's one extra facet: low-protein diets can be dangerous.

I'll analyze that in detail in my next post.

 

 

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Posted in balanced diets, dietary protein content, Dieting, Exercise possibilities, Governmental Efforts, Healthy food shopping, medically-oriented background info, physician initiatives, Publications, scientific controversies, Unhealthy eating, Vegetables, Weight Loss | No Comments »

It goes far beyond football, boxing and hockey

Wednesday, December 7th, 2011

The brain is vulnerable to trauma

I feel like I've opened the proverbial can of worms, finding, in this case, a topic that keeps expanding. I started with reading an article in The New York Times about the death of a professional hockey player, but I quickly delved into the medical literature.

I've spent much of the day reading article after article on traumatic brain injury  (TBI), which can be mild or severe, and another entity called chronic traumatic encephalopathy or CTE, one that's frequently been in the news over the last two years. Let's start with TBI. I'll be writing about teens and younger kids. I'll deal with CTE in another post focused on adults.

A Center for Disease Control and Prevention (CDC)  report in the most recent edition of the Journal of the American Medical Association reviewed nonfatal TBI related to either sports or recreational activities in kids age 19  or younger. The numbers involved were staggering, nearly 175,000 per year being seen in Emergency Departments (EDs).

A large majority of those sports and recreation-related TBI ED visits were by boys and the annual total of those ED trips increased markedly during that nine-year time frame. They were injured biking, playing football, soccer, basketball or while engaging in miscellaneous playground activities. They went to the ED in smaller numbers for injuries suffered in many other activities, including horseback riding, ice skating, ATV riding, tobogganing and even golfing (here the injuries included those related to golf carts). Surprisingly, skateboarding accounted for only a fourth of the ED visits for biking and football accidents and TBI was less frequently seen.

A helmet is a good start

As my wife and I drive around town, we often see college students riding their bikes at night while helmet-less and light-less. I fear for their brains.

There's another, less well-accepted entity, so-called "Second Impact Syndrome." I read an article about this in a February 2009 article by two authors on the faculty of the University of California, Irvine School of Medicine. In this scenario athletes who've had a TBI then have a second brain injury when they go back to playing their sport far too quickly. The initial injury may have been relatively mild; the recurrent trauma may kill them in a matter of minutes.

Another review of this  syndrome said 94 catastrophic head injuries had been reported in American high school and college football players in a 13-year time frame, 92 in high schoolers.  Seven of ten had a prior concussion in the same football season; over a third played with continuing symptoms.

This speaks to the crucial question of when an athlete (or a bike or horseback rider) who has suffered TBI should return to their sport/activity. Last night I called a younger friend who had been bucked off his spooked mare and suffered a concussion eight days ago. He was still having headaches and agreed with me that it was far too soon to get back on his horse.

A new CDC program called Heads Up offers TBI guidelines for coaches, parents and physicians.

 

 

 

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Posted in Chronic Traumatic Encephalopathy (CTE), concussion, Exercise possibilities, medically-oriented background info, mental health issues, physician initiatives, Sports-related brain injuries, Traumatic brain injury (TBI) | 1 Comment »

Do our kids have a bleak future?

Saturday, November 19th, 2011

As close to a salad as he'll get

I'm taking a break today from my series of posts on greenhouse gases, alternative energy source, volcanoes and global warming. All of those will affect the generations to come and those now growing up, but I want to re-examine another side of their issues. This morning I read two articles and one newspaper report on the heart health prospects for our American kids (and, by extension, kids elsewhere in the developed/rapidly developing world). The initial article came from a section of the Wall Street Journal I hadn't gotten around to reading yesterday and was about to recycle. Then I saw a title that caught my eye, "Kids' Hearth Health Is Faulted."

I found a CDC website with an explanation of the National Health and Nutrition Examination Survey, NHANES. This is a continuation of a US Public Health Service effort started 40 years ago and is updated annually. Medically-trained interviewers may well come to your town and even to your front door someday. The data they obtain is used in many ways (I'll paste in a website that leads you to some comments on NHANES as well as to a link to a video).

Now a portion of the survey/study looked at 5,450 kids between 12 and 19, finding they were a long ways from matching the American Heart Association's (AHA) seven criteria for idea cardiovascular health (see 2nd link below to Harvard's Beth Israel Deaconess Medical Center's article on the subject). The adult health measures, known as Life's Simple 7, are: 1). Never smoked or quit more than a year ago; 2). Body Mass Index (a measure of height versus weight) <25; 3). Physical activity on a weekly basis for 75 minutes (vigorously) or 150 minutes (moderate intensity).; 4). a healthy diet (four or more components meeting AHA guidelines); 5). total cholesterol <200 mg/dL; 6). blood pressure (BP) <120/80; and fasting blood glucose (AKA blood sugar) <100 mg/dL. The original article was published in the journal Circulation January 20, 2010 and is available free online. The metrics are slightly different for kids.

So where do our kids stack up? If you exclude eating a healthy diet, only 16.4% of boys and 11.3% of girls meet the standards for the other six criteria; if you include diet, none of them do. They don't eat four to five servings of fruits and vegetables a day; they also don't get enough whole-grains or fish and they consume far to much salt and sugar-sweetened drinks. Only one fifth of them even eat "fairly well."

drop that hamburger and run for an hour

Many of then also don't exercise on a daily basis for at least sixty minutes (50% of the boys do and 40% of the girls). More than a third are overweight or obese.

There's some hope: a just-published article in the New England Journal of Medicine, examining the data from four studies following 6328 kids, found that those who do manage to lose weight had lower risk for type 2 diabetes, hypertension, abnormal lipids and carotid artery disease.

So I'm heading to the health club and will read the 2010 Circulation tome on an exercise bike.

Thus far my one biologic grandson, about to be 12,  is physically active and slender. I'll encourage him to stay that way and the non-biologic grandkids to follow his example.

More on this subject to come.

Check out these articles:

Survey Results and Products from the National Health and Nutrition Examination Survey

AHA Defines "Ideal" Cardiovascular Health

 

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Posted in Complications of Obesity, diabetes type 2, Exercise possibilities, Food Choices, Food-related disease, Life Expectancy, medically-oriented background info, our kids and their weight issues, physician initiatives, Publications, strategies for healthy aging, Unhealthy eating | 3 Comments »

Early cholesterol testing now recommended

Saturday, November 12th, 2011

We're seeing more obese kids

With our sweeping epidemic of childhood obesity ( current estimates say over one-sixth of American kids are obese, three times the prevalence rate seen thirty years ago), it's time to take some additional steps. On Friday 11, 2011, sweeping new guidelines for childhood lipid testing were espoused by both the NIH's Nation Heart Lung and Blood Institute and The American Academy of Pediatrics. I found these, of all places, not on the websites of the two august bodies, but on the front page of the Wall Street Journal, an NPR article and in the Los Angeles Times.

The actual article in the journal Pediatrics, won't be out for two more days and should find a fair amount of opposition. Previous position papers by the AAP and the US Preventive Services Task Force have either suggested lipid studies be done in focused groups (eg. family history of heart disease or lipid disorders) or, if universally, no earlier than age 20. The CDC (actually the acronym has changed since it's now the Centers for Disease Control and Prevention), in a 2010 report, commented that a single elevated LDL cholesterol reading in a child may be found to be normal in subsequent testing.

The current recommendation panel, headed by Dr. Stephen R. Daniels, an MD, PhD who is Chairman of Pediatrics at the University of Colorado School of Medicine, is quick to avoid any suggestion of widespread statin use for children found to have high levels of "bad cholesterol," LDLs over 190 milligrams per deciliter. Another panel member, Dr. Elaine M. Urbana, director of preventive cardiology at the Cincinnati Children's Hospital Medical Center, was quoted as saying, "This documents on the fact that this generation may be the first to have a shorter life expectancy than their parents."

So go back to the facts: one-third of US kids are overweight and about 12.5 million of them are actually obese. Even here in Colorado, the thinnest state in the nation, I see some of those kids every day. We're not just talking about high schoolers; some of these fat kids are as young as two.

What's missing is a balanced diet with emphasis on fruits and vegetables and a reasonable amount of daily exercise.

earlier blood tests may let them live longer

Daniels comments, "...the atherosclerosis process really begins early in life." he also said, "Heart disease is the number one killer in our society...people who are able to maintain a low risk through childhood and early adulthood have a lower risk (of dying from coronary artery disease)."

From my perspective, it's our responsibility as parents and grandparents, to help prevent childhood obesity, the accompanying risk of later type 2 diabetes and the huge risk of early heart disease. I filled out a health history form yesterday and noted my mother had a heart attack at age 74 (she lived 'till 90), but ignored my father's need for an artery unclogging procedure shortly before his 90th birthday. That may be something I can put off by eating well and exercising, but that's not the focus here.

I never want to see a child or grandchild die of a heart attack in their 50s or 40s or 30s or 20s.

So blood tests between ages 9 and 11 and again between 17 and 21 make sense.

 

 

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Posted in diabetes type 2, Governmental Efforts, Healthy eating, Life Expectancy, Obesity, our kids and their weight issues, physician initiatives, Publications, Unhealthy eating, Vegetables | No Comments »

Seemingly disparate topics tied together with MRSA

Thursday, November 10th, 2011

Staph bacteria growing on a culture media

I read two NYT articles  about medical diseases that conflate to a really frightening juncture. They led me to find background data from a medical website and to do a Google search on one lead author.

Let's start with MRSA, the acronym for methicillin-resistant Staphylococcus aureus.  Roughly 25% of us are staph carriers, but only 2% of us carry MRSA, the antibiotic resistant form that causes deadly complications so frequently  and is so difficult to treat. Infections with "ordinary" staph bacteria can be very serious, but respond, in most cases, to the drugs commonly used. The NIH has an excellent summary of MRSA issues and I'll paste in a link to it below.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004520/

An August 11, 2011 NYT article mentioned that MRSA skin infections occur in those more prone to cuts and scrapes: athletes, the military and our kids among them. A professor of Medicine and Pediatrics at UC Davis Medical School is quoted as saying, "...in most communities, community acquired MRSA has become the dominant cause of soft tissue infection requiring emergency department care and inpatient care."

In a previous post I noted that a neighbor ended up in our local ICU for a prolonged stay after a scape on his elbow resulted in a rapid spread of redness up his arm unto his chest. As you might surmise, this was an MRSA-caused illness.

MRSA is a major urgent medical problem; almost 19,000 people died from this dire staph in 2005. In that timeframe most MRSA infections were felt to occur in immunocompromised patients.

But now hospital admissions for skin infection in kids have climbed; the rate of these more than doubled between 2000 and 2009. The overall rate still seemed low, 9.4 cases per 10,000 children, but that translates into just under 72,000 kids being hospitalized in that one year.

In the average year roughly 4,000 kids wind up in pediatric ICUs yearly because of severe flu infections and of course many times as many have mild cases of flu. The current study, headed by an associate professor of Anesthesia at Harvard, looked at children who got flu infections during the 2009-2010 H1N1 epidemic and were admitted to ICUs in 35 different locations. Of those  838 youngsters, nearly nine percent, 75 of those kids, died; their median age was 6.

More than a quarter of the children in the study were previously considered totally healthy; they didn't have asthma or a neurological disease; they were not immunosuppressed and didn't have other chronic conditions. So of the total, 251 kids were otherwise healthy prior to getting the flu; 18 of them died. The only predictor of death in healthy children in this group was MRSA infection; if they had this co-existing risk factor their risk of dying increased eight times when compared to those who did not have MRSA.

Please ask your pediatrician about flu vaccination

My take on the study, and that of the lead researcher, is it's time to make sure our kids and grandkids get vaccinated for flu on a yearly basis.  There are still people who never want their children vaccinated; physicians in almost all cases would disagree with them.

Talk it over with your own pediatrician.

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Posted in Life Expectancy, medically-oriented background info, physician initiatives, Publications, scientific controversies | 1 Comment »

Dengue fever; global warming effects versus a new hope

Friday, August 26th, 2011

avoid at all costs

I haven't thought about Dengue Fever in years, probably since I returned from an Air Force tour of duty in the Philippines in 1986. Now global warming and a fascinating NPR tidbit brought it back to the forefront of my consciousness.

Dengue, a major cause of illness and death in the tropics and subtropics, is a viral illness spread by mosquitoes. Worldwide it causes up to 100 million infections and 25,000 deaths per year. The typical result is a high fever, headache, muscle/joint/bone pain and a rash. There is no effective vaccine available and avoidance of mosquito bites is the most effective preventive strategy.

So why am I concerned enough about dengue to bring it to your attention? Simple, we're traveling more, cases have been seen in Florida, Texas and Hawaii; it's an endemic disease in Puerto Rico and, with our climate heating up, I'm concerned that we may see the disease spreading further in the United States and elsewhere. I'll add a link to information on dengue from the NIH's PubMed website.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002349/

There's another concern; more than 5% of Key West residents monitored in a 2009 study had antibodies to the one of the four viruses that cause dengue. That puts them at risk for a much more severe form of the disease if they're bitten by a mosquito carrying a different dengue virus than they were first exposed to.

Dengue hemorrhagic fever is a serious problem, though relatively uncommon. It can lead to a generalized rash, bruising and bleeding and, potentially to a shock-like state, liver and brain damage, and seizures. Early diagnosis and aggressive care measures  can improve survival rates, but half of untreated patients who go into shock die.

Most physicians in the US probably have never seen a case of dengue hemorrhagic fever. I have, in the Philippines, but that was the result of working there for a year and a half. So bringing this disease to the attention of doctors (and potential patients) in locations that previously haven't seen dengue makes sense to me.

the old way to control mosquitoes

But now for the good news. Research scientists in Australia recently released specially-bred mosquitoes, infected with a bacteria that is a parasitic microbe, seen in roughly a sixth of other neotropical insects. Apparently Wolbachia-infected mosquitoes will not spread dengue to humans, but when allowed to intermingle with uninfected mosquitoes, results, in a relative brief period, in those insects also being unable to spread the disease. The article on these experiments came out in Nature, online on the 24th and in print yesterday.

http://www.nature.com/nature/journal/v476/n7361/abs/nature10356.html

Now it's time for large-scale projects in multiple countries, but it looks like dengue may finally have met its match.


 

 

 

 

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A better school lunch: Greeley in the New York Times Breaking News

Saturday, August 20th, 2011

It's time for a better school lunch

I was reading the NYT breaking news on my Kindle this morning, when to my surprise I saw an article, "Schools Restore Fresh Cooking to the Cafeteria," on school lunches in Greeley, Colorado. We live 20-25 miles northwest of Greeley and I'd never thought of the city as being a hotbed of innovation.

At a tad under 93,000 inhabitants, Greeley is mid-sized at best, but 60% of its 19,500 students qualify for lower-priced or free meals, so they have decided those meals will be healthy ones.They're not alone in this endeavor. The Physicians Committee for Responsible Medicine has a campaign whose motto is,"Foods served in schools should promote the health of all children." Their 2008 school lunch report card ranked twenty school districts across the nation with letter grades from A to F.

Here's that URL: http://www.healthyschoollunches.org/reports/report2008_intro.cfm

At the top with A's were schools in Montogomery County, MD, Omaha, NE, and Pinellas County, FL, I was pleased that my grandson Jordi's schools in Fairfax County, VA got an A-.  At the bottom were schools in two areas of Louisiana. I bet Greeley will climb up the list in the next few years.

So what's their plan? Like many Colorado schools, they've participated in Cooks for America, a group that runs a chef's boot camp for school cooks  Here's what that organization's website says: "Distinguishing the Cook for America® approach from that of countless other school food reform projects is its emphasis on holistic, systemic change through the creation of a school foodservice work force that is both capable of preparing healthy scratch-cooked meals from whole, fresh foods, and empowered and motivated to do so."

Greeley schools will be cooking from scratch, roughly three-fourths of the time at the start of this school year according to the NYT article, and aim to reach 100% in the 2012-2013 time frame. They'll be using fresh ingredients, avoiding chemicals (e.g., their bean burritos will have 12 ingredients this year versus 35 last year).

Although Colorado has the lowest obesity rate in the nation, Weld County, where Greeley is located, had rates growing faster than much of the state. So the numbers were crunched with amazing results: cooking from scratch will actually save money. A large foundation grant helped with construction and new equipment and the old central kitchen was renovated, so the budget for staff was actually reduced.

Chenically-colored macaroni and cheese

The district hired an experienced executive chef who trained at the Culinary Institute of America (the other CIA) and worked in high-end restaurants. He hopes his concepts for healthy cooking will wend their way back to the districts homes. One of his innovative ideas is to replace the chemically-colored commercial macaroni and cheese with a version whose familiar yellow will come from the Indian spice turmeric. His salad dressing will have no sugar and only a quarter of the sodium that's been present in the factory-made variety.

My hat's off to Greeley.

 

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Posted in cooking: new ideas, Food Choices, Governmental Efforts, Healthy eating, our kids and their weight issues, physician initiatives, tricks and gimmicks | No Comments »