ACP Internist

Wednesday, October 21, 2009

So that's what that slide does.

The disclosure slide has become a standard feature of medical lectures. A good percentage of the time speakers disclose nothing, or something silly like their love of the Yankees.

But yesterday, at the ACR meeting, I saw a disclosure slide that even the speaker himself described as "very conflicted." This doctor was there to offer his expertise on osteoporosis drugs so it's not exactly shocking that's he worked with a long list of pharma companies.

Even so, his potential conflicts stuck in my mind, popping up when he expressed suspicion about the effectiveness of generics or pooh-poohed concerns about side effects. For example, "there have been more papers written about osteonecrosis of the jaw associated with bisphosphonates than there have been cases."

Of course, there's no way to know if an interested expert is actually conflicted, but I do now have the anecdotal proof that those disclosure slides serve as more than just an opening for the speaker's warm-up joke.

Labels: conflict-of-interest, rheumatology

Narrowing the focus on fibromyalgia

If attendees at the Association of Rheumatology Health Professionals' fibromyalgia debate were expecting strident disagreement, they were likely disappointed. There were some points of disagreement, but a fair number of accord as well.

Anthony Russell, MD, of the University of Alberta, who took the anti-fibromyalgia position, listed off the long history of trendy, unexplained fibromyalgia-like illnesses and pointed out the common incidence of such symptoms. (See ACP Internist's Q&A with Frederick Wolfe for more in this vein.) Physicians shouldn't reinforce patients' perceptions that they are sick, he argued.

Leslie Crofford, MD, of the University of Kentucky, didn't disagree that fibromyalgia is only the latest name for what has been a persistent, inexplicable patient complaint. But she argued that patients benefit from having their problem labeled as fibromyalgia. A diagnosis makes patients less likely to consume additional time and resources looking for an explanation, she said, and more able to move on the managing their condition.

She also offered a suggestion to decrease the likelihood of having a similar debate about whatever disease is in style five years from now: "We will all do better if we stop the foolishness of changing the name."

Labels: fibromyalgia, rheumatology

A rheumatology study for primary care

Researchers are usually calling on docs to follow guidelines, but a study presented yesterday revealed that ignoring a certain guideline for gout therapy could actually improve results. The study experimented with increasing gout patients' doses of allopurinol over recommended levels. "The problem with the dosing guidelines is that many patients fail to reach target serum uric acid levels," explained study author Lisa Stamp. "We are effectively undertreating."

The study increased the drug dose to try to get patients to the target serum uric acid level of 6 mg/dL, in some cases exceeding recommendations by as much as 400 mg/day. A few of the patients (3 of 45) developed rashes at the higher doses, but 86% of the participants hit the target.

The findings are particularly important for primary care physicians, who may be following the guidelines more rigidly than are doctors who have more experience with the medication. "I think this is going to support what rheumatologists are doing anyway," said Dr. Stamp.

Labels: rheumatology

The ACR's got milk...and lemonade and water.

The point of the rheumatologic press conference I attended this afternoon was probably supposed to be the results of the research presented, but what I found most interesting were the ways that researchers found to collect and torment their subjects.

First up, a study that investigated the possibility that skim milk consumption can lower serum uric acid concentrations, thereby reduced the risk of gout or gout attacks. They found that cow milk--but not soy--did decrease levels when it was consumed in 80 gram servings by healthy young men. The author helpfully explained how much milk that is for us measurement-challenged listeners--5 to 7 glasses at a sitting. And all that milk was drunk by guys who weren't even sick! Hope they at least went back home and challenged their buddies to the gallon challenge.

If you don't like milk, perhaps you would have preferred to join the Coke-sponsored osteoarthritis trial which asked participants to drink two bottles of diet lemonade (spiked with either glucosamine or placebo) every day in a single sitting. The bad news for them was that all that lemonade-chugging had no apparent effect on their knees.

Beverages seemed to be the theme of the day, although the lucky participants in the next trial didn't have to change their consumption, just monitor it. The interesting thing about them is that they were recruited through a Google ad. The ad recruited gout sufferers across the country to report all kinds of data about their behavior when they are and aren't having gout attacks. Turns out that not drinking water seems to increase the risk of a gout attack.

The data led one astute reporter to wonder whether the milk-drinkers would have done just as well chugging water. It's an issue for further study, admitted the researcher. But where's the fun in that?

Labels: rheumatology

Rheumatology: Ill-advised session titles

Another conference, another edition of Ill-advised Session Titles. The American College of Rheumatology is meeting in Philadelphia next week and we will bring you some serious news from there. But first, some semi-funny titles. (Not to start a turf war or anything, but rheumatologists just don't seem to be as creative as the medical group managers.)

We've got some metaphors: "Getting a Grip on Arthritis" and "Tip-Toeing Around Arthritis and Foot Pain" and one movie reference: "Something's Gotta Give: Couples Coping with Chronic Pain." I know, not very hilarious.

The sad thing is that rheumatology has lots of potential. Take this session, for example: "The Effect of an Iyengar Yoga Program to Minimize Falls and Build Balance Confidence, Postural Stability and Improved Gait in Women Between Ages 60 and 75." How much more likely would you be to attend if it were called "Downward dog for dowagers" or "Say 'Om,' Grandma"?

Labels: Ill-advised session titles, rheumatology

Best of convention hopping

After a whirlwind of conventions, it's time to head back to the office. But, before I go, a few non-clinical highlights:

Most unusual swag: It looks like a highlighter, but one end is a hand sanitizer spray, and the other is lip balm.

Rudest attendee: Raised his hand in the MIDDLE of a session and said, "I don't mean to be rude, but this is a little boring."

Strangest group psychology: the outsized appeal of free food. It's not as if any conference attendees would have trouble affording a couple of bucks for a snack. In fact, many of us are on expense accounts. But throw out a tray of muffins or a case of soda and we're stuffing our pockets like a horde of street urchins.

Weirdest souvenir: The ACR daily paper encouraged attendees to purchase a "Rodman Commemorative Gout Print." Your guess is as good as mine.

Strangest wardrobe: It may have related to the high percentage of foreign attendees, but spotted at ACR were a mullet, a pink fringed suit, and a study author's top so sparkly it could have blinded a cameraman.

Marketing gone wildest: In a montage promoting MGMA 2009, screen faded from e=mc2 to DEN=mc2, to DENVER. Hunh?

Most mysterious session title: Indian Hedgehog and Parathyroid Hormone-related Protein Regulate Articular Chondrocyte Differentiation.

Labels: MGMA conference, rheumatology

Getting the gist

In my last ACR session (the convention continues through tomorrow, but our blog coverage finishes today), a psychiatrist spoke about explaining statistical risk to patients, a topic I've covered before.

One of her key points was that patients need to understand the gist, rather than the specifics, of risk. She used a clever example to make this point. Two patients are offered a surgical treatment that carries a 2% mortality risk. This risk is explained to them several weeks before the surgery, and then they are asked about it immediately beforehand. Patient A remembers the risk as 10%, while Patient B remembers a 0% risk. Even though Patient B's recollection is numerically closer to correct, it's less useful, because Patient A has correctly understood the gist that the surgery holds some mortality risk.

So what's the practical import? When talking to patients about risk, worry more about whether they seem to have gotten the general idea (aka the gist) rather than whether they can recite stats back to you verbatim.

Labels: patient communication, rheumatology

Time for something besides medicine

This afternoon, I attended an ACR session on part-time medicine. A lot of the described advantages and disadvantages were ones you might have guessed (advantage: more free time, disadvantage: less money), but one speaker made some interesting points about the relative merits of working part-time vs. job sharing.

A lot of it comes down to overhead and benefits. Part-timers may be expected by their partners to continue covering an equal share of the overhead, but job-sharers may not be able to get full benefits. The speaker was a fan of job sharing, which she herself does, but she noted that finding a very compatible partner is of course a pre-requisite to making it work.

Both speakers said that it's usually better to cut back on the number of days you work rather than the number of hours, because a half-day will easily slide into a full day as patients and paperwork pile up. All in all, they made part-time work sound pretty lovely. Anyone want to be half of a medical reporter?

(Just kidding, unless you're willing to do half the work while I get all the salary.)

Labels: rheumatology, Workplace issues

More reasons to quit smoking and lose weight

Smoking has already been shown to be a risk factor for rheumatoid arthritis. But a new study, presented this morning at ACR, expands the evidence against tobacco by finding that RA patients who quit smoking had significantly less disease activity than patients who continued to smoke. The research was based on a registry of 1,405 patients.

Being overweight, on the other hand, increases your risk for osteoarthritis. Swedish researchers compared BMI to likelihood of receiving a knee or hip replacement due to arthritis and they found that the more you weigh, the better the chance that you'll need a joint replaced. The finding held true even in the normal weight population, and when controlled for inflammatory and metabolic factors. The findings make it pretty clear that the greater joint load placed on the hips and knees of overweight people is responsible for the arthritis, said the study author. He recommended diet and exercise, although he wasn't terribly optimistic that patients would be leaping off their couches based on the study. "Maybe we need to work at this for 10 or 20 or 30 years," he said.

Labels: obesity, rheumatology

New uses for old drugs

There's something pleasingly efficient about research that finds new applications for existing therapies. A few such studies were presented today at the ACR meeting.

Hydroxychloroquine, an antimalaria medication, appears to be an effective treatment for both lupus and rheumatoid arthritis. In the lupus study, the drug protected against kidney damage, a common complication of lupus. The arthritis study, an observational trial, added to the evidence base for hydroxycloroquine by finding that it reduced the likelihood that RA patients would develop diabetes. Researchers suggested the drug--which is generic and costs less than $60 a month--might also be good for lipids and platelets.

Finally, a new study found that Cialis can increase blood flow to other parts of the body besides the one for which it was intended. In a trial of 25 patients (mostly women), the drug effectively treated secondary Raynaud's phenomenon, a condition which causes fingers to turn white and blue when exposed to cold. Guess now you can "be ready" to go build a snowman.

Labels: drugs, rheumatology

Good news, bad news

From ACR today:

The good news is that a new study found that TNF-antagonists do not increase the risk of cancer for patients with rheumatoid arthritis. The Spanish study looked at a database that included 14,001 person years and found very similar incidences of cancer in TNF-taking and control patients.

The bad news is that, even though rheumatologic patients are often at a higher risk of developing zoster infections, immunosuppressive therapies can prevent them from getting the vaccine. According to CDC recommendations, the zoster vaccine should be avoided in patients who are on high-dose corticosteroids or TNF-alpha-blockers. It can be given once patients have been off the drugs for at least a month, said this morning's presenter.

Labels: rheumatology

The patient who ruins your day

At ACR yesterday, Dennis Boyle, MD, led an entertaining, interactive session on dealing with difficult patients. In addition to clips from Cool Hand Luke, he offered some perspective on the visits that no one wants to have.

First, recognize that you bring your own issues to the encounter, which will affect how you respond to the patient. Dr. Boyle described how he used to complain about his problem patients to a psychiatrist friend until the shrink asked, "Did you realize that all your difficult patients remind you of your mother?"

More seriously, he reminded attendees that most angry patients are actually more afraid or sad than angry, and that open-ended questions ("Tell me why...") should be used to get their story. It's also important to actually listen to them when they're talking, and use reflective listening ("It sounds like...") to make patients feel understood, to control rambling stories, and to help you remember details for later charting.

Labels: patient communication, rheumatology

Very different conferences

Attending two conferences in a row can be confusing, but I'm pretty sure the rheumatology session I just attended came out of a MGMA attendee's nightmare.

The purpose of the session was to convince rheumatology health professionals (who are co-meeting with the ACR) to refer their arthritis patients to occupational, vocational and physical therapy if they report any effects of their illness on work performance. The speakers made important points about how early interventions and workplace accomodations can lower overall costs by reducing absenteeism and disability payments.

But I think it's no coincidence that 3 of the 4 presenters were from countries with socialized medicine (England, Canada and the Netherlands). For example, the British speaker described the accomodations required for an office clerk with rheumatoid arthritis, which included a flat-screen computer, a customized ergonomic chair, speech-recognition software and construction of a ramp.

In the UK, she explained, the government will cover a signficant chunk of the modification costs. In the US, I thought, the manager of that office would be cringing even at the recommendation to buy an electric stapler.

Labels: rheumatology, Workplace issues

Drugs, drugs, and...tai chi?

At most conferences, a press badge causes other attendees to avoid you if anything. But here at the American College of Rheumatology meeting, drug reps are drawn to my press ribbon like flies to honey. And they were in full swarm at a press conference this afternoon.

Early data on several experimental rheumatologic therapies was presented, including an injection for treatment-resistant gout and a new painkiller for knee osteoarthritis, as well as two potential competitors to Fosamax (in case Sally Field's commercials haven't already made it clear, there seems to be some money to made here). One of the drugs is a twice-yearly biologic and the other reduces glucocorticoid-induced fracture risk.

None of the drugs have been FDA-approved yet, though, so it should be a while before the drug reps are chasing you down the hall to discuss them.

The press conference did offer one non-drug therapy for knee osteoarthrtis--the ancient Chinese art of tai chi. Patients who did tai chi for 12 weeks had better function, balance and quality of life scores than those who did conventional stretching and wellness education. The researcher did warn that the tai chi exercises should be modified for OA patients because as typically done, tai chi can actually cause a lot of knee injuries. There's always a catch.

Labels: drugs, rheumatology

Physicians using antibiotics, sedatives as placebos

Internists and rheumatologists are using antibiotics and sedatives for their placebo effect, researchers reported.

Before 1960, sugar pills were common and ethical. Then advances in pharmaceuticals and in informed consent cast placebos in a negative light. But internists are using them, so researchers looked at internists and rheumatologists use of placebos, figuring they dealt with "debilitating chronic clinical conditions that are notoriously difficult to manage."

Researchers collected 679 responses split nearly evenly bewteen internist and rheumatologists. About half prescribe placebos, using saline (3%), sugar pills (2%), over the counter analgesics (41%), vitamins (38%) antibiotics (13%) and sedatives (13%). Nearly half said they use placebos monthly.

The researchers concluded, "Recommending relatively innocuous treatments such as vitamins or over the counter analgesics to promote positive expectations might not raise serious concerns about detrimental effects to patients' welfare. Prescribing antibiotics and sedatives when they are not medically indicated, however, could have potentially important adverse consequences for both patients and public health."

How are you using placebos in your practice?

Labels: ethics, placebos, rheumatology

One more ill-advised session title

I'll be blogging from the annual meeting of the American College of Rheumatology next week, and for the most part, their session titles are depressingly matter-of-fact. "Translating Rheumoatoid Arthritis Treatment Guidelines into Quality Measures" and that sort of thing.

Some of them are intimidatingly specific: "Elevated Production of Interleukin 1β (IL-1β) and Tumor Necrosis Factor α (TNF-α) by Perpheral Blood Mononuclear Cells (PBMC) is Associated With Increased Hip Fracture Risk in Elders: The Framingham Osteoporosis Study."

But only this one caught my eye for sheer weirdness of imagery: "Preserving the Beans and Other Points in the Evaluation and Management of Chronic Kidney Disease." Yum.

Labels: Ill-advised session titles, rheumatology

ACP Internist hosted Grand Rounds on June 16, wrapping up the best of the medical blogosphere. Click here for the complete wrap-up.

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American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

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A collaborative medical blog started by Neil Shapiro, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

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Robert M. Centor, FACP, contributes short essays contemplating medicine and the health care system.

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EverythingHealth is designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

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Getting Better is the continuation of Dr. Val Jones' previous blog at Revolution Health. It is devoted to helping people understand health issues from a balanced, scientifically sound perspective.

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A roundup of health policy news drawn from a database of hundreds of Web sites.

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Michael Benjamin, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

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The alter ego of Kevin Pho, ACP Member, is the closest thing to royalty in the medical blog world.

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Wednesday, October 21, 2009

So that's what that slide does.

Tuesday, October 20, 2009

Narrowing the focus on fibromyalgia

A rheumatology study for primary care

Monday, October 19, 2009

The ACR's got milk...and lemonade and water.

Friday, October 16, 2009

Rheumatology: Ill-advised session titles

Wednesday, October 29, 2008

Best of convention hopping

Tuesday, October 28, 2008

Getting the gist

Time for something besides medicine

More reasons to quit smoking and lose weight

Monday, October 27, 2008

New uses for old drugs

Good news, bad news

The patient who ruins your day

Sunday, October 26, 2008

Very different conferences

Drugs, drugs, and...tai chi?

Friday, October 24, 2008

Physicians using antibiotics, sedatives as placebos

Monday, October 20, 2008

One more ill-advised session title

Contact ACP Internist

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