Why Are We Ignoring Guideline Recommendations?

In the current issue of The American Journal of Medicine, Lopes et al(1) report discouraging news. They examined a large cohort of patients taken from 3 large randomized double-blind clinical trials and asked the question: “Are patients in these trials who were in atrial fibrillation being treated with antithrombotic therapy in accordance with widely accepted guidelines?” Unfortunately, only a small percentage (13.5%) of the patients with atrial fibrillation in these trials were, in fact, receiving indicated prophylactic antithrombotic therapy with warfarin. This is not an unusual finding. Many other studies have documented that guideline recommendations are followed for a disappointingly small portion of inpatients and outpatients.(2, 3) It has become clear that in daily clinical practice, guideline advice is often ignored or overlooked. What can be the explanation for this lack of compliance with evidence-based counsel? Guidelines are written by acknowledged experts in the areas covered, and the published results of guidelines are widely disseminated. Why don't physicians follow this advice? Surely, it is not because as a group we are careless or don't care about the results of carefully conducted clinical trials.

I have given this topic a great deal of thought in recent months, and my personal opinion is that neither negligence nor hostility to guidelines underlies poor physician compliance. Rather, I believe that a number of other factors help to explain the observed failure to use evidence-based guideline information:

1. Currently, there are literally hundreds and hundreds of guidelines available. These have all been carefully prepared by a variety of different professional societies. Some of these guidelines are quite long, at times exceeding 300 pages in length. Considering the number of guidelines and their size, it is not surprising that busy physicians do not have time to peruse, no less absorb, the presented material. Furthermore, in a hectic physician work day with its constant interruptions, one can easily understand why guideline-recommended interventions might be overlooked.

2. Clinicians in practice develop a series of personal “tried and true” approaches for managing the disease entities commonly seen in their daily work. Once established and thought to be successful, the use of these personal approaches becomes second nature to the physician. Changing these personal protocols feels like an unnecessary imposition given the many demands already craving attention in the busy clinician's work day. Again, given these comfortable patterns of practice, it is not surprising that new evidence-based clinical approaches would not be adopted easily.

3. Physician training, particularly in the past, emphasized individual patient therapeutic regimens with an avoidance of rigid “cookbook”-style order sets. Thus, many physicians think that a rigid “cookbook” style of medical practice, including the use of standard order sets based on guideline recommendations, represents an improper approach to patient care.

4. With specific reference to preventive antithrombotic therapy in patients with atrial fibrillation, patients and doctors dislike warfarin therapy, the most widely recommended antithrombotic therapy for patients with atrial fibrillation. The many dietary and pharmacologic caveats associated with warfarin therapy, the need for frequent monitoring of drug effect, and the fear for both patient and physician of unexpected bleeding complications make this agent one of the least desired therapeutic recommendations in most practices, including my own.

5. Finally, large, randomized, global, double-blind trials produce results that reflect outcomes for the majority, but not all of the patients, in that particular trial. There are usually a substantial minority of patients in each of these trials, the results of which lead to evidence-based guideline recommendations, who do not behave like the majority. Physicians may think that their particular patients do not fit the pattern observed in the large clinical trials. To some extent they might be perfectly right in this assumption. This attitude might lead some doctors to advise a therapeutic protocol different from that suggested by the results of the large, “gold standard,” randomized, double-blind clinical trials.

Whatever reasoning affects clinical decision making in these patients, the end result is often nonadherence to guidelines. Unfortunately, guideline-directed therapy for a particular condition has been shown to lead to better clinical outcomes compared with “eminence-based,” personally derived, therapeutic strategies. In general, the majority of patients with a particular entity would almost certainly benefit if guideline-directed therapy were universally applied. This is the reasoning behind many quality initiatives. As noted above, research in this arena has supported the idea that guideline-based therapy produces better clinical outcomes compared with arbitrarily selected therapeutic regimens. If we accept the latter 2 statements, the question then arises, “how can we get doctors to adhere more closely to evidence-based therapy as suggested in clinical guidelines?”

Our experience at the University of Arizona College of Medicine has suggested one potential solution to the conundrum just described, that is, more liberal use of standard order sets embedded in electronic medical records and computer order systems. An example of how such standardization might improve clinical quality is as follows. A few years ago, it was noted by our quality department at the University Medical Center that documentation of counseling concerning cessation of tobacco use was often lacking in the charts of our patients discharged after an acute myocardial infarction. To remedy this problem, a requirement was placed in our discharge order set for these patients to receive this counseling. The patient could not be discharged from the hospital until a doctor or nurse involved in the patient's care had checked a box in the electronic orders stating that such appropriate advice concerning smoking cessation had indeed been carried out. This small and simple alteration in our discharge order set guaranteed that all such patients received tobacco cessation recommendations.

This change in our approach to smoking cessation counseling resulted in essentially 100% compliance with the need to give this advice. Why not use the same strategy for other order sets with similar guideline-advised therapeutic orders placed in the discharge orders together with drop-down boxes detailing reasons why a particular intervention was not used? The full order set would not be accepted until all such queries had been satisfactorily managed. The introduction of evidence-based orders as well as statements detailing why exceptions to these orders were made would ensure that the clinician had been made aware of the importance of dealing with these interventions. In this manner it would be possible to ensure a very high rate of compliance with evidence-based guideline recommendations. Presumably, this would also lead to improved quality of care for these patients.

As always, I'd be interested in hearing your comments on this important topic. Feel free to post a comment on our blog.

References
1. Lopes RD, Starr A, Pieper CF, et al. Warfarin use and outcomes in patients with atrial fibrillation complicating acute coronary syndromes. Am J Med. 2010;123:134–140.

2. Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines?. JAMA. 1999;282:1458–1465.

3. Bach DS, Awais M, Gurm HS, Kohnstamm S. Failure of guideline adherence for intervention in patients with severe mitral regurgitation. J Am Coll Cardiol. 2009;54:860–865.

-- Joseph S. Alpert, MD
Editor-in-Chief, The American Journal of Medicine

This article originally appeared in the February 2010 issue of The American Journal of Medicine.

Warfarin Use and Outcomes in Patients with Atrial Fibrillation Complicating Acute Coronary Syndromes

Warfarin is associated with better 6-month outcomes among patients with atrial fibrillation complicating an acute coronary syndrome, but its use is not related to Congestive heart failure, Hypertension, Age>75 years, Diabetes, Prior Stroke/transient ischemic attack (CHADS2) score or bleeding risk.

Abstract

Background
We examined warfarin use at discharge (according to Congestive heart failure, Hypertension, Age > 75 years, Diabetes, Prior Stroke/transient ischemic attack score and bleeding risk) and its association with 6-month death or myocardial infarction in patients with post-acute coronary syndrome atrial fibrillation.

Methods
Of the 23,208 patients enrolled in the Platelet IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy, Platelet IIb/IIIa Antagonist for the Reduction of Acute Coronary Syndrome Events in a Global Organization Network A, and Superior Yield of the New Strategy of Enoxaparin, Revascularization and Glycoprotein IIb/IIIa Inhibitors trials, 4.0% (917 patients) had atrial fibrillation as an in-hospital complication and were discharged alive. Cox proportional hazards models were performed to assess 6-month outcomes after discharge.

Results
Overall, 13.5% of patients with an acute coronary syndrome complicated by atrial fibrillation received warfarin at discharge. Warfarin use among patients with atrial fibrillation had no relation with estimated stroke risk; similar rates were observed across Congestive heart failure, Hypertension, Age > 75 years, Diabetes, Prior Stroke/transient ischemic attack (CHADS2) scores (0, 13%; 1, 14%; ≥ 2, 13%) and across different bleeding risk categories (low risk, 11.9%; intermediate risk, 13.3%; high risk, 11.1%). Among patients with in-hospital atrial fibrillation, warfarin use at discharge was independently associated with a lower risk of death or myocardial infarction within 6 months of discharge (hazard ratio 0.39; 95% confidence interval, 0.15-0.98).

Conclusion
Warfarin is associated with better 6-month outcomes among patients with atrial fibrillation complicating an acute coronary syndrome, but its use is not related to CHADS2 score or bleeding risk.

To read this article in its entirety, please visit our website.

-- Renato D. Lopes, MD, PhD, Aijing Starr, Carl F. Pieper, DPH, Sana M. Al-Khatib, MD, MHS, L. Kristin Newby, MD, MHS, Rajendra H. Mehta, MD, MS, Frans Van de Werf, MD, PhD, Kenneth W. Mahaffey, MD, Paul W. Armstrong, MD, Robert A. Harrington, MD, Harvey D. White, DSc, Lars Wallentin, MD, Christopher B. Granger, MD

This article originally appeared in the February 2010 issue of The American Journal of Medicine.

Aspirin for the Primary Prevention of Stroke and Myocardial Infarction: Ineffective or Wrong Dose?

More than 40 million Americans take aspirin for the primary or secondary prevention of myocardial infarction and stroke, including approximately half of all those aged 65 years or more.(1) The daily dose varies from 81 mg (1 baby aspirin) to 325 mg (1 adult aspirin). The efficacy of aspirin for the secondary prevention of myocardial infarction and stroke has been validated by multiple randomized clinical trials.(2)

The first randomized clinical trial to establish the efficacy of aspirin for primary prevention was the US Physicians Health study published in 1989.(3) More than 22,000 male US physicians were randomized to 325 mg of aspirin every other day versus placebo and followed for 5 years. The incidence of fatal or nonfatal myocardial infarction was 44% lower in those taking aspirin (odds ratio = 0.56; 95% confidence interval, 0.45-0.70; P < .0001). The decreased risk of myocardial infarction was present in those aged 50 years or more. There was no significant difference in mortality or stroke incidence.(3)

To read this article in its entirety, please visit our website.

-- James E. Dalen, MD, MPH

This article originally appeared in the February 2010 issue of The American Journal of Medicine.

More Thoughts on Tackling Obesity

I want to thank all the commentators for their insightful and excellent responses to my editorial on obesity. I agree with everything that was said including comments on how to create positive rewards (money) and negative conditioning (higher prices for high calorie junk foods) to assist in the battle against obesity. Our cafeteria here at the University Hospital is considering raising prices on unhealthy food choices in order to lower them on heart healthy selections. I also support the idea of a "sin" tax on high calorie junk food such as soft drinks that are loaded with one or another form of glucose. In the final analysis, education is going to be critical in this arena. We need to start teaching children about good nutritional choices in the very earliest school grades and continue the lessons right through high school and beyond. As the many respondents to the blog stated "We need to get serious about controlling obesity". Thanks again to all who wrote comments. Joseph Alpert, editor, AJM.

The American Journal of Medicine Blog: 'So, Doctor, What's So Bad About Being Fat?' Combating the Obesity Epidemic in the United States

The American Journal of Medicine Blog: 'So, Doctor, What's So Bad About Being Fat?' Combating the Obesity Epidemic in the United States

Statins Decrease the Occurrence of Venous Thromboembolism in Patients with Cancer

In addition to cholesterol-lowering effect, statins exhibit anti-thrombotic and anti-inflammatory properties, which may affect coagulation cascade. In cancer patients, the use of statins decreased the odds of developing venous thromboembolism, when compared with non-statins users.

Abstract
Background
Recent data suggest a reduction in the occurrence of venous thromboembolism in select groups of patients who use statins. The objective of this study is to evaluate the impact of statin use on the occurrence of venous thromboembolism in patients with solid organ tumor.

Methods
We conducted a retrospective, case-control study reviewing 740 consecutive patients with a diagnosis of solid organ tumor who were admitted to the Albert Einstein Medical Center, Philadelphia, Penn, between October 2004 and September 2007. Patients treated with anticoagulation therapy before their first admission were excluded. The occurrence of venous thromboembolism, risk factors for venous thromboembolism, and statin use were recorded. Patients who never used statins or had used them for less than 2 months were relegated to the control group.

Results
The mean age of the study population was 65 years, and 52% of the patients were women and 76% were African American. The occurrence of venous thromboembolism was 18% (N = 132), and 26% (N = 194) were receiving statins. Among patients receiving statins, 8% (N = 16) developed a venous thromboembolism compared with 21% (N = 116) in the control group (odds ratio 0.33; 95% confidence interval, 0.19-0.57). A logistic regression analysis including risk factors for venous thromboembolism (metastatic disease, use of chemotherapy, immobilization, smoking, and aspirin use) along with statin use yielded the same results.

Conclusion
This study suggests that the use of statins is associated with a significant reduction in the occurrence of venous thromboembolism. This pleiotropic effect warrants further investigation.

To read this article in its entirety, please visit our website.

-- Danai Khemasuwan, MD, Matthew L. DiVietro, DO, Kawin Tangdhanakanond, MD, Sherry C. Pomerantz, PhD, Glenn Eiger, MD

This article originally appeared in the January 2010 issue of The American Journal of Medicine.

Care of the Cancer Survivor: Metabolic Syndrome after Hormone-Modifying Therapy

Hormone-modifying cancer therapy can lead to increased risk of metabolic syndrome. Vigilant screening and treatment for metabolic syndrome is an important component of care for cancer survivors.

Abstract
Emerging evidence implicates metabolic syndrome as a long-term cancer risk factor but also suggests that certain cancer therapies might increase patients' risk of developing metabolic syndrome secondary to cancer therapy. In particular, breast cancer and prostate cancer are driven in part by sex hormones; thus, treatment for both diseases is often based on hormone-modifying therapy. Androgen suppression therapy in men with prostate cancer is associated with dyslipidemia, increasing risk of cardiovascular disease, and insulin resistance. Anti-estrogen therapy in women with breast cancer can affect lipid profiles, cardiovascular risk, and liver function. As the number of cancer survivors continues to grow, treating physicians must be aware of the potential risks facing patients who have been treated with either androgen suppression therapy or anti-estrogen therapy so that early diagnosis and intervention can be achieved.

To read this article in its entirety, please visit our website.

-- Amanda J. Redig, PhD, Hidayatullah G. Munshi, MD

This article originally appeared in the January 2010 issue of The American Journal of Medicine.

'So, Doctor, What's So Bad About Being Fat?' Combating the Obesity Epidemic in the United States

Each week, many of my middle-aged patients ask me the question cited above. Obesity has become so commonplace in the United States that thin, healthy individuals are becoming the exception rather than the rule. With the rising prevalence and incidence of obesity in our society, patients have begun seeing this state of body habitus as the norm rather than the exception. “What's the matter with being a little overweight, doc; everyone in my family is fat, so why not me?”

In response, I deliver my “fat” talk. In this sermonette on obesity, I stress the many increased health risks that overweight individuals incur: atherosclerosis, hypertension, gallstones, diabetes, colonic adenomas, degenerative joint disease, sleep apnea, deep venous thrombosis, and pulmonary embolism, among others. I try to communicate to my obese patients the importance of modest and gradual weight loss as compared with the cycle of rapid weight loss and equally rapid weight gain that is so common in our society. “Bouncing your weight up and down may even put you at greater risk for heart disease,” I continue, hoping that my message will take root in the patient's mind. “Regular exercise such as daily walking is a great help in losing weight. Try to cut back on portion size, simple carbohydrates such as sugar and products made with white flour, as well as saturated fat in your diet. Would you like to speak with one of our dieticians?”

My daily preaching often goes unheeded and leads me and my internal medicine colleagues to become cynical about the possibility of ever convincing our patients to lose weight. This is, unfortunately, the price to be paid in a society that gratifies itself with every type of food taken in excess combined with widespread physical inactivity. Many of my patients ask about the surgical procedures that can lead to dramatic weight loss. I inform them that these operations carry risk and are really designed only for patients who are massively obese. Fortunately, most of my patients are only 30-50 pounds overweight and not massively obese.

Clinical science and epidemiology have convincingly shown that increasing body mass correlates well with rising blood pressure, lipid levels, and blood glucose, all important atherosclerotic risk factors. In general, the more obese the individual, the worse the combined burden of atherosclerotic risk factors. However, obesity alone is not a perfect predictor of atherosclerotic disease risk. For example, a number of epidemiological studies have shown that obesity alone is not a major predictor of coronary heart disease death once more prominent atherosclerotic risk factors that correlate with obesity have been removed. Thus, an obese person with normal values for blood pressure, serum lipids, and blood glucose is not at major risk for the development of atherosclerotic arterial disease. The most important issue to be considered in patients who are overweight is not weight per se, but rather the metabolic consequences of obesity.

As noted earlier, obese patients are at risk for many other health problems. Thus, an obese patient who is normotensive, normolipemic, and euglycemic might still develop severe, crippling degenerative arthritis or sleep apnea as a result of his/her adiposity. Consequently, physicians, including internists and other primary care providers, as well as specialists such as cardiologists, rheumatologists, endocrinologists, gastroenterologists, and other internal medicine specialists, need to look at the entire picture of a particular obese patient's health and not just his/her risk for coronary artery disease. Indeed, physicians should not reassure obese patients about their future health if their atherosclerotic risk factors are normal, because other disease entities might come to plague such patients in the future.

It is important that modest weight loss in an obese patient with atherosclerotic risk factors can result in remarkable improvement in these risk factors. Indeed, it has often been observed that modest (~10% of body weight) loss of weight produces marked amelioration in elevated blood pressure, abnormal serum cholesterol, and glucose intolerance. Moreover, demanding that a patient try to reach his/her ideal body weight is often unrealistic and discourages compliance with the prescribed program of diet and exercise. In the end, “the enemy of good is perfect,” that is, we should strive to enlist our patients in a program that produces moderate, sustained weight loss rather than advising a draconian strategy that will almost certainly fail.

The National Task Force on the Prevention and Treatment of Obesity advises that the best strategy for weight loss is one of moderate caloric restriction, increased activity (that is, regular exercise), and a supportive program of behavioral modification to assist patients in remodeling their eating habits and style (1).

As always, I welcome your comments on our blog.

1) National Task Force on the Prevention and Treatment of Obesity. Dieting and the development of eating disorders in overweight and obese adults. Arch Intern Med. 2000;160:2581–2589.

-- Joseph S. Alpert, MD, editor-in-chief

This article was originally published in the January 2010 issue of The American Journal of Medicine.

A Fall in Ghana

Presentation
A fall marked the beginning of a perilous medical journey for a 34-year-old man. He had traveled from the United States, where he lives with his family, to Accra, Ghana for business purposes and was well until the ninth day of his trip, when he fell and twisted his lower back. Although he was able to stand immediately afterwards, the back pain worsened as the morning progressed and was then compounded by malaise, leading him to spend the remainder of the day in bed. He had no neurologic deficits or loss of bowel or bladder continence.

That evening, the patient developed a fever of 102.1° F (38.9° C) with chills and progressive malaise. His health status began to rapidly deteriorate, and he was evacuated to the United States the following day. En route he developed hypoxia, which was corrected with supplemental oxygen. Tachycardia and hypotension responded to intravenous fluid. Upon arrival, he was evaluated at a community hospital, where he received empiric ceftriaxone. He was determined to be in critical condition and was transferred urgently to the intensive care unit (ICU) of the National Naval Medical Center in Bethesda, Md for further management.

Previously healthy, the patient had an unremarkable medical history. A systems review revealed no further complaints, and he had been fully compliant with his malaria prophylaxis. Throughout his stay in Ghana, he had no contact with sick people, animal exposure, or insect bites. He did not leave the luxury hotel complex and only ate approved prepared meals, except for 1 dinner on day 3, which took place at a high-end restaurant with colleagues. His vaccinations were current.

To read this article in its entirety, please visit our website.

-- Michael Eberlein, MD, PhD, Mayy F. Chahla, MD, Sammy A. Baierlein, MD, Richard T. Mahon, MD

This article was originally published in the December 2009 issue of The American Journal of Medicine.

D-dimer Testing in Patients with Suspected Pulmonary Embolism and Impaired Renal Function

The specificity of D-dimer testing in patients with suspected pulmonary embolism and impaired renal function is significantly decreased. Nonetheless, performing D-dimer tests is still useful because computed tomography scanning can be withheld in a significant proportion of these patients.

Abstract

Background
Determination of pretest probability and D-dimer tests are the first diagnostic steps in patients with suspected pulmonary embolism, which can be ruled out when clinical probability is unlikely and D-dimerlevel is normal. We evaluated the utility of D-dimer testing in patients with impaired renal function.

Methods
D-dimer tests were performed in consecutive patients with suspected pulmonary embolism and an unlikely clinical probability. Creatinine levels were assessed as clinical routine. Glomerular filtration rate was calculated using the Modification of Diet in Renal Disease formula. Correlation between D-dimer level and renal function and proportions of patients with normal D-dimer in different categories of estimated glomerular filtration rate (eGFR) were assessed. Different categories of decreasing eGFR were defined as: normal renal function (eGFR >89 mL/min), mild decrease in eGFR (eGFR 60-89 mL/min), and moderate decrease in eGFR (eGFR 30-59 mL/min).

Results
Creatinine levels were assessed in 351 of 385 patients (91%). D-dimer levels significantly increased in 3 categories of decreasing eGFR (P = .027 and P = .021 for moderate renal impairment compared with mild renal impairment and normal renal function, respectively). Normal D-dimer levels were found in 58% of patients with eGFR >89 mL/min, in 54% with eGFR 60-89 mL/min, and in 28% with eGFR 30-59 mL/min.

Conclusions
The specificity of D-dimer testing in patients with suspected pulmonary embolism and decreased GFR is significantly decreased. Nonetheless, performing D-dimer tests is still useful because computed tomography scanning can be withheld in a significant proportion of these patients.

To read this article in its entirety, please visit our website.

-- Reza Karami-Djurabi, MD, Frederikus A. Klok, MD, Judith Kooiman, Sophie I. Velthuis, Mathilde Nijkeuter, MD, PhD, Menno V. Huisman, MD, PhD

This article was originally published in the November 2009 issue of The American Journal of Medicine.

The Obesity Paradox, Weight Loss, and Coronary Disease

Although an obesity paradox exists, in that coronary heart disease patients with higher body mass index or higher percent body fat have lower mortality than those with less obesity, the results of this study support the safety and potential long-term benefits of purposeful weight loss in overweight and obese patients with coronary heart disease.

Abstract

Purpose
Because obesity is a cardiovascular risk factor but is associated with a more favorable prognosis among cohorts of cardiac patients, we assessed this “obesity paradox” in overweight and obese patients with coronary heart disease enrolled in a cardiac rehabilitation and exercise training (CRET) program, making this assessment in patients classified as overweight/obese using both traditional body mass index (BMI) and percent body fat assessments. Additionally, we assessed the efficacy and safety of purposeful weight loss in overweight and obese coronary patients.

Patients and Methods
We retrospectively studied 529 consecutive CRET patients following major coronary events before and after CRET, and compared baseline and post program data in 393 overweight and obese patients (body mass index [BMI] ≥25 kg/m2) divided by median weight change (median = −1.5%; mean +2% vs −5%, respectively). In addition, we assessed 3-year total mortality in various baseline BMI categories as well as compared mortality in those with high baseline percent fat (>25% in men and >35% in women) versus those with low baseline fat.

Results
Following CRET, the overweight and obese with greater weight loss had improvements in BMI (−5%; P<.0001), percent fat (−8%; P <.0001), peak oxygen consumption (+16%; P <.0001), low-density lipoprotein cholesterol (−5%; P <.02), high-density lipoprotein cholesterol (+10%; P <.0001), triglycerides (−17%; P<.0001), C-reactive protein (−40%; P <.0001), and fasting glucose (−4%; P = .02), as well as marked improvements in behavioral factors and quality-of-life scores. Those with lower weight loss had no significant improvements in percent fat, low-density lipoprotein cholesterol, triglycerides, C-reactive protein, and fasting glucose. During 3-year follow-up, overall mortality trended only slightly lower in those with baseline overweightness/obesity who had more weight loss (3.1% vs 5.1%; P = .30). However, total mortality was considerably lower in the baseline overweight/obese (BMI ≥25 kg/m2) than in 136 CRET patients with baseline BMI <25 kg/m2 (4.1% vs 13.2%; P <.001), as well as in those with high baseline fat compared with those with low fat (3.8% vs 10.6%; P <.01).

Conclusions
Purposeful weight loss with CRET in overweight/obese coronary patients is associated with only a nonsignificant trend for lower mortality but is characterized by marked improvements in obesity indices, exercise capacity, plasma lipids, and inflammation, as well as behavioral factors and quality of life. Although an “obesity paradox” exists using either baseline BMI or baseline percent fat criteria, these results support the safety and potential long-term benefits of purposeful weight loss in overweight and obese patients with coronary heart disease.

To read this article in its entirety, please visit our website.

-- Carl J. Lavie, MD, Richard V. Milani, MD, Surya M. Artham, MD, MPH, Dharmendrakumar A. Patel, MD, MPH, Hector O. Ventura, MD

This article was originally published in the December 2009 issue of The American Journal of Medicine.

Nailing the Diagnosis!

Physical examination plays a crucial role in patient evaluation by confirming the hypotheses during history taking, suggesting new clues, and directing investigations. We describe how the recognition of a nail abnormality led us to the recognition of the cause of long-standing lymphedema and pleural effusion.

To read this article in its entirety, please visit our website.

-- Srinivas Rajagopala, MD, Navneet Singh, MD, DM, Dheeraj Gupta, MD, DM, FCCP

This article was originally published in the December 2009 issue of The American Journal of Medicine.

Commentary: The Bottom Line

Consideration of the forgoing will lead you to realize that the practice of medicine is predominantly a humanistic act. Physicians must care about their patients, and they must constantly improve their scientific knowledge about disease. To care and not know is dangerous. To know and not care is even worse. Caring and knowing must be combined to succeed in doctoring.
-- J. Willis Hurst, MD1

The thin thread that holds our existence in this life is broken every time we become sick. We seek medical care to restore our homeostasis through remedies and drugs provided by medical healers. Nonetheless, there is an untold and intense connection between the patient and the clinician that has been traditionally upheld as the key element of the therapeutic patient–physician relationship. In fact, more than the remedies, as patients, we expect to be listened to and cared for by compassionate and competent physicians. A listening and caring physician may turn out to be a more effective healer than the most scientifically updated physician who has little empathy. However, the major threat to this sacred connection between the provider and the patient is the growing practice of the business of medicine where care is sacrificed to see a greater number of “clients,” and thus increased billing.

The practice of clinical medicine is rapidly transforming with the current worldwide economic crisis. Although no one denies the importance of running a practice in a fiscally responsible way, the core ideals behind “physicianhood” and its mission also seem to be faltering.

To read this article in its entirety, please visit our website.

-- Carlos Franco-Paredes, MD, MPH, Phyllis Kozarsky, MD

This article was originally published in the December 2009 issue of The American Journal of Medicine.

An Aberrant Internal Carotid Artery in the Mouth

The cervical internal carotid artery normally runs straight to the skull base without branching.(1) However, aberrant courses of the extracranial internal carotid artery are not rare and may place the vessel in close relationship with the pharyngeal wall.(2, 3) We present this clinical observation to draw the readers' attention on a probably underappreciated anatomic variation.

A 77-year-old woman had long-standing moderate dysphagia and right-sided foreign body sensations in the throat. She had no history of alcohol or tobacco abuse. On examination, smooth irritation-free mucous membranes were found, but a funicular pulsatile mass was detected on the posterior pharyngeal wall on the right. Endoscopy displayed that the mass continued down to the hypopharynx. It was finally attributed to an aberrant course of the internal carotid artery. The patient was instructed to advise every treating physician of this anatomic variation and to abstain from sharp-edged food such as chicken bones and fish.

Pronounced extracranial aberrations of the internal carotid artery have a calculated incidence of 5% in the general population and can often be found bilaterally. They result from embryologic maldevelopment and age-related loss of elasticity in the vessel wall. These anatomic variations remain asymptomatic in the majority of cases but can also become apparent with dysphagia, pharyngeal foreign body sensations, intraoral pulsations, or signs of cerebrovascular insufficiency in case of sharp vessel bends.1, 2, 3 If placed in close opposition with the pharyngeal wall (Figure 1A and B), an aberrant internal carotid artery is at risk of injury during intubation, endoscopy, and routine pharyngeal or dental procedures. It may also be misdiagnosed as a parapharyngeal tumor.2, 3 Therefore, the awareness of extracranial aberrations of the internal carotid artery is essential for every clinician.

References

1. Paulsen F, Tillmann B, Christofides C, et al. Curving and looping of the internal carotid artery in relation to the pharynx: frequency, embryology and clinical implications. J Anat. 2000;197:373–381.
2. Hertzanu Y, Tovi F. Radiology case of the month (Aberrant internal carotid artery manifesting as a pharyngeal mass). J Otolaryngol. 1992;21:294–296.MEDLINE
3. Ricciardelli E, Hillel AD, Schwartz AN. Aberrant carotid artery (Presentation in the near midline pharynx). Arch Otolaryngol Head Neck Surg.1989;115:519–522. MEDLINE

-- Jens Pfeiffer, MD, Gerd J. Ridder, MD

This article was originally published in the March 2009 issue of The American Journal of Medicine.

Back to the Future: Medical Students Can Matter Again

Over the last 5 years, we have spent considerable time directly teaching students and housestaff and have been involved in numerous meetings of academic physicians concerned about the apparent erosion in quantity and quality of medical student and resident teaching at our medical schools and teaching hospitals.

The causes of this progressive deterioration in what many consider the best medical education system in the world are myriad: Economic challenges forced faculty to spend much of their time doing direct clinical work rather than teaching; program directors have needed to spend more time and effort on regulatory documentation; administrative restrictions have been placed on medical student participation in patient care; duty hour constraints have been placed on resident work schedules, thereby decreasing the amount of time that residents can devote to teaching students as well as each other; and inpatient physicians are given performance metrics that emphasize efficiency of patient flow at the expense of bedside teaching and role modeling. Departments of medicine have evolved into business centers or “product lines” instead of the medical center's academic compass.

Teachers have less time to teach; residents have less time to learn; and medical students are often relegated to the role of voyeurs. And from this environment we hope to find the solution to reverse the trend of dwindling number of students seeking careers as general internists and academicians.

To read this article in its entirety, please visit our website.

-- Joseph S. Alpert, MD, Brian F. Mandell, MD, PhD

This article was originally published in the November 2009 issue of The American Journal of Medicine.

Should We Maintain an Open Mind about Homeopathy?

Once upon a time, doctors had little patience with the claims made for alternative medicines. In recent years the climate has changed dramatically. It is now politically correct to have an open mind about such matters; “the patient knows best” and “it worked for me” seem to be the new mantras. Although this may be a reasonable approach to some of the more plausible aspects of alternative medicine, such as herbal medicine or physical therapies that require manipulation, we believe it cannot apply across the board. Some of these alternatives are based on obsolete or metaphysical concepts of human biology and physiology that have to be described as absurd with proponents who will not subject their interventions to scientific scrutiny or if they do, and are found wanting, suggest that the mere fact of critical evaluation is sufficient to chase the healing process away. These individuals have a conflict of interest more powerful than the requirement for scientific integrity and yet defend themselves by claiming that those wanting to carry out the trials are in the pocket of the pharmaceutical industry and are part of a conspiracy to deny their patients tried and tested palliatives.

To read this article in its entirety, please visit our website.

-- Michael Baum, MD, ChM, Edzard Ernst, MD, PhD

This article was originally published in the November 2009 issue of The American Journal of Medicine.

Bayesian Meta-analysis of Hormone Therapy and Mortality in Younger Postmenopausal Women

This careful meta-analysis indicates that hormone therapy reduces total mortality by 25% in younger postmenopausal women. A similar reduction in mortality has been seen in randomized trials and observational studies.

Abstract

Background
There is uncertainty over the risks and benefits of hormone therapy. We performed a Bayesian meta-analysis to evaluate the effect of hormone therapy on total mortality in younger postmenopausal women. This analysis synthesizes evidence from different sources, taking into account varying views on the issue.

Methods
A comprehensive search from 1966 through January 2008 identified randomized controlled trials of at least 6 month's duration that evaluated hormone therapy in women with mean age <60 years and reported at least one death, and prospective observational cohort studies that evaluated the relative risk of mortality associated with hormone therapy after adjustment for confounding variables.

Results
The results were synthesized using a hierarchical random-effects Bayesian meta-analysis. The pooled results from 19 randomized trials, with 16,000 women (mean age 55 years) followed for 83,000 patient-years, showed a mortality relative risk of 0.73 (95% credible interval 0.52-0.96). When data from 8 observational studies were added to the analysis, the resultant relative risk was 0.72 (credible interval 0.62-0.82). The posterior probability that hormone therapy reduces total mortality in younger women is almost 1.

Conclusions
The synthesis of data using Bayesian meta-analysis indicates a reduction in mortality in younger postmenopausal women taking hormone therapy compared with no treatment. This finding should be interpreted taking into account the potential benefits and harms of hormone therapy.

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-- Shelley R. Salpeter, MD, Ji Cheng, MSc, Lehana Thabane, PhD, Nicholas S. Buckley, Edwin E. Salpeter, PhD (Posthumous)

This article was originally published in the November 2009 issue of The American Journal of Medicine.

Alcohol and Illicit Drug Use as Precipitants of Atrial Fibrillation in Young Adults: A Case Series and Literature Review

Alcohol and illicit drugs are associated with atrial fibrillation. Avoidance of these substances can help prevent further paroxysms. Apart from avoidance, there are no existing guidelines on the management of lone atrial fibrillation, precipitated by alcohol/illicit drugs. “Real life” management varies widely.

Abstract

Background
Atrial fibrillation in young patients (≤45 years) is uncommon. There is the perception that the precipitant in such cases is alcohol, but we also have noted cases related to illicit drug abuse. There are no clear guidelines on the treatment of atrial fibrillation in patients presenting with “lone atrial fibrillation” precipitated by alcohol or illicit drugs.

Methods
We retrospectively analyzed young (defined as ≤45 years) patients with “lone” atrial fibrillation who were admitted to the hospital with electrocardiographically confirmed diagnosis of atrial fibrillation or atrial flutter, precipitated by either alcohol or illicit drugs, over a 6-year period.

Results
Eighty-eight patients aged ≤45 years were admitted with atrial fibrillation or atrial flutter. In 22 patients, (mean [SD] age 33.6 [8.4] years; 20 male), alcohol (n = 19) and/or illicit drugs (n = 3) were found to be the precipitant. One patient required electrical cardioversion, with the remaining patients cardioverting back to sinus rhythm either pharmacologically or spontaneously. Twelve (54.5%) were investigated for atrial fibrillation burden by 24-hour Holter monitoring and the majority also underwent a transthoracic echocardiogram (81.8%). At discharge, 14 (63.6%) patients were treated with anti-arrhythmic drugs and 10 received either antiplatelets or anticoagulants. Most (85%) patients were followed-up for at least 12 months, during which time 6 had further paroxysms; all of whom continued to abuse either alcohol or illicit drugs.

Conclusions
Alcohol and illicit drugs are arrhythmogenic and are associated with atrial fibrillation. Apart from abstinence, the optimal management of such patients and the long-term effects of these substances on the heart and atrial fibrillation recurrences are still unclear.

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-- Suresh Krishnamoorthy, MRCP, Gregory Y.H. Lip, MD, Deirdre A. Lane, PhD

This article was originally published in the September 2009 issue of The American Journal of Medicine.

Incidence of Thrombocytopenia in Hospitalized Patients with Venous Thromboembolism

Although heparin-associated thrombocytopenia is uncommon, the incidence can be minimized by use of low molecular weight heparin, particularly if extended prophylaxis or extended treatment is required.

Abstract
Purpose
To determine the incidence of heparin-associated thrombocytopenia in patients receiving prophylaxis or treatment for venous thromboembolism.

Methods
We assessed the database of the National Hospital Discharge Survey from 1979 through 2005 and complemented this with a meta-analysis of published literature.

Results
Among 10,554,000 patients discharged from short-stay hospitals throughout the US with venous thromboembolism during the 27 years of study, secondary thrombocytopenia was coded in 38,000 patients (0.36%). From 1979 through 1992, secondary thrombocytopenia was coded in only 0.15% of hospitalized patients with venous thromboembolism. The frequency increased sharply to 0.54% from 1993 through 2005. Secondary thrombocytopenia was rarely diagnosed among 1,446,000 patients aged <40 years and among 77,000 women who had venous thromboembolism with deliveries. Meta-analysis of published literature showed a higher incidence among patients who received unfractionated heparin (UFH) for prophylaxis than those who received low-molecular-weight heparin (LMWH) for prophylaxis. Treatment resulted in smaller differences of the incidence between UFH and LMWH.

Conclusion
Heparin-associated thrombocytopenia is rare among patients aged <40 years and women following delivery. The risk of heparin-associated thrombocytopenia is more duration-related than dose-related, and higher with UFH when used for an extended duration. Our findings and those of the literature suggest that although heparin-associated thrombocytopenia is uncommon, the incidence can be minimized by use of LMWH, particularly if extended prophylaxis or extended treatment is required.

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-- Paul D. Stein, MD, Russell D. Hull, MBBS, MSc, Fadi Matta, MD, Abdo Y. Yaekoub, MDc, Jane Liang, MSc

This article was originally published in the October 2009 issue of The American Journal of Medicine.

The Patient–Physician–Industry–Government Partnership: A Societal Good

I recently celebrated the 40th anniversary of my graduation from medical school at a class reunion in Boston. While reminiscing with my former classmates about the joys and tribulations of living as a student during the 1960s, a discussion arose regarding what was available to us then in the area of pharmacotherapeutics compared with what is now available for practicing physicians. In regard to treatments for cardiovascular disease, my area of internal medicine subspecialty, we had nitrates for angina pectoris; digitalis preparations and furosemide for heart failure; hydrochlorothiazide, reserpine, guanethidine, hydralazine, and alpha-methyldopa for hypertension; quinidine, lidocaine, and procainamide for arrhythmias; and bile acid resins for hypercholesterolemia. Since 1969, with the advances in basic research supported by the National Institutes of Health (NIH) and the development of new drugs by the pharmaceutical industry, we now have available for clinical use the beta-adrenergic blockers and calcium-entry blockers for the treatment of angina pectoris; angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for heart failure; new drugs for systemic and pulmonary hypertension; thrombolytics for myocardial infarction; statins for hypercholesterolemia; and new antiplatelet drugs. These newer therapies have favorably affected both the prevention and treatment of cardiovascular disease.

As examples, over the past 40 years, major reductions have occurred in the numbers of acute myocardial infarctions, in part related to innovative drug therapies for cholesterol elevations, hypertension, and smoking addiction.

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- William H. Frishman, MD

This article was originally published in the October 2009 issue of The American Journal of Medicine.