Remember When We Used to Prescribe Inhaled Steroids for Asthma and COPD?

Press Release: Annual Conference of the Universal College of Chest Physicians October 2085; New Chicago, Mars.

The annual conference enjoyed another record attendance today as attendees flocked to Dr. Ramachandran III’rds keynote address reviewing exploits of physicians in the early part of the century. Dr. Ramachandran highlighted some key decisions and their consequences, such as the ACGME’s decree in 2032 that all residents should be swaddled before their scheduled hourly nap times. This of course led to the now infamous Great Hospital Apocalypses of 2033, 2034, and 2035.

Perhaps nearly as intriguing was the plight of inhaled corticosteroids for the treatment of respiratory diseases like asthma and COPD in the beginning of the 21st century. The period began with greater awareness and concern regarding the use of long acting beta agonist (LABA) bronchodilators such salmeterol. That risk was highlighted by findings published in the SMART trial (access through Chest archives here). There was increased concern regarding the potential harm caused by LABA which culminated in the placement of warnings on medications which contained LABA bronchodilators. These medications, experts said, were to be prescribed with extreme caution because of the possible increase in harm, particularly among children.

Scholars of the early 21st century thus highly recommended that asthmatics, especially children, be started on steroid inhalers before having to resort to using inhaled LABAs. Many also theorized that inhaled steroids had a protective effect when combined with LABA’s, possibly ameliorating their potential danger. Thus many at the time recommended a strategy of not using LABA inhalers at all, unless also simultaneously prescribing an inhaled steroid.

However, problems with this approach started to appear late in the first decade of the century. The TORCH study, a trial using combined inhaled LABA/inhaled steroids in adults with COPD suggested that there was an increased incidence of pneumonia among those treated with inhaled steroids. Early in the second decade a pivotal study then demonstrated that asthmatic children treated with inhaled steroids ended up being about half an inch shorter than they might have otherwise been (interestingly, a later study in 2035  correlated the reduced height with a statistically significant decrease in NBA dunking). Continue reading

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End of Life Conversations are Becoming End of Life Confrontations

“How Dare You!”

Life can change in a heartbeat. Most of us believe that our lives, our loves and all the that things that make us who we are is a gift from a higher power. One that can be taken away as swiftly as it is given. But somewhere in the shuffle of taking kids to practice, catching up on emails, worrying about bills, and the search for the perfect barbecue, it’s all too easy to forget the truth of life. The one truth. The one single thing that life guarantees each and every one of us. From the moment we take our first breath,  life makes to us but one promise. The promise that our life will someday end.

“Who do you think you are?”

For some of us, death comes after a lifetime of achievement, for others all too soon. For many it will be feared, for others it will be welcomed as their bodies wither away. But for more and more of us in our increasingly sterile and safe society, it is simply not to be thought of at all. An unwelcome stepchild locked tightly away in the attics of our consciousness. Like a demon in waiting, we reshape it, remake it, remold it, until it becomes an ever distant sunset that bookends a romantic dream of a life full of love, accomplishment, achievement.

“You have no right to say that!”

Until finally, that inevitable day approaches. A man or woman in a white coat tells you the terrible news that your loved one is passing away. That yes,  they are alive and can be kept alive, but there is practically no chance that they could recover. They will never go back to the person they were before.

“Where’s my regular doctor?” Continue reading

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5 Ways Healthcare Reform May Impact Medical Education

Guest Post by Ta’Rikah Jones

Unless Congress completely smothers the Affordable Care Act (ACA), its changes will shake healthcare to the foundations as millions of people gain access to insurance and expanded medical care.

The ACA’s goal is to move Americans toward a health insurance umbrella for everyone while striving to control costs and drastically alter the insurance industry. Potentially every facet of healthcare could be affected, from the doctor’s office to research labs. Changes could even reach into healthcare education.

The law will change the number of patients seeking care, how much doctors are paid and may make some med school students even more uneasy about school loans.

These are some ways the ACA may affect medical education:

1. More primary care

The law seeks to foster primary care and boosts Medicare payments to primary and internal medicine physicians significantly while lowering payments for subspecialty doctors. Also, payment and coverage for preventative care would rise along with primary care.

This could slow the drop in students who pursue primary care in medical school. For years students migrated into more lucrative subspecialties, leaving only a small percentage of students interested in general medicine.

The act also calls for expanding some scholarship and repayment programs for primary care doctors and expands nurse and primary care training.

Continue reading

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How to Attend a Medical Conference Without Actually Being There.

A version of this article is also posted at KevinMD.com.

Well, I’ve done it again. It seems that every time I try to make the early registration deadline for a conference, something seems to come up. One of the kids gets sick, a transmission breaks, I have a crazy week at work, you know, life.

Unlike the past few years however, I’m very excited to say that I will be making it to the American College of Chest Physician’s annual scientific meeting (Chest 2013) in Chicago at the end of October.

While I wasn’t able to make it to the conference last year, it turns out that I didn’t have to miss everything because I had a new and unique tool at my disposal. A tool that allowed me to catch a surprising amount of the action and actually obtain some of the benefits of the conference without actually being there: social media. Continue reading

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Why I Stopped Working with Express Scripts

Mail order pharmacies like Express Scripts and Medco have become increasingly prominent players in health care. But these companies are a lot more than simply mail order pharmacies, they are in fact a new generation of pharmacy benefit managers (PBM’s). PBM’s are essentially middle-men between insurance and pharmacy, with companies like Express Scripts merging the dual functions of a PBM and pharmacist into one. PBM’s manage and administer medication benefits for insurance companies. The largest insurance companies contract with them not only to manage the medication benefits of their clients (that would be you), but also to contain costs. Since insurance companies are not in the business of directly managing pharmacy services themselves, they contract with PBM’s to coordinate and manage their patients’ insurance benefits for them. If a PBM can do that at a lower cost, they save (make) money for themselves and the insurance company.

Mail order pharmacies are in a unique position to do this, as they don’t have to maintain brick-and-mortar outlets, and can use the mail to reduce costs . With such an advantage in cost containment, mail order PBM’s are quickly pushing traditional brick and mortar outfits to the periphery (remember Netflix vs. Blockbuster?). Mail order pharmacies are thus becoming giants in this industry. In 2012, Express Scripts completed a $29 billion acquisition of Medco, to create the country’s largest PBM, a publicly traded company with $100 billion in annual revenue. Continue reading

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Infographic: 10 Revolutionary Medical Advancements on the Horizon.

I’ve said it never and I’ll say it again: Ya gotta love infographics! How else could you turn an otherwise random and often sleep-inducing jumble of important looking illustrations and maybe facts into an eye catching array that draws you in like a fly to a plasma screen? So compelling, their like the pop-up books of science.  Such an obvious idea, right? Yet their still new enough to set off your spell check. (Go ahead, open up Word. I’ll wait. See?)

So I was joyed to accept an invitation to post Caduceusblog’s first-ever infographic. Thanks to the graphic smiths at Master’s in Health Administration Degrees for submitting this post (even if they are a bit numerically challenged;). You can see the original post here

Continue reading

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September 7 is Pulmonary Fibrosis Awareness Day, Learn More About This Deadly Disease.

Idiopathic Pulmonary Fibrosis  is disease which involves progressive scarring of the lungs of unknown cause (hence the term idiopathic).  The median survival from the time of diagnosis is 2 to 3 years, though the course is variable and many patients deteriorate rapidly.

There is little in the way of effective treatment and no cure other than lung transplantation.

There are excellent resources available to learn about this disease.

For Patients: The Pulmonary Fibrosis Foundation and Coalition for Pulmonary Fibrosis. Both resources provide information regarding patient support groups,  fund raising, and advocacy.

For Physicians: The ACCP’s OneBreath website includes this patient brochure. I have found this helpful in answering many common questions for patients with newly diagnosed IPF. The author is a pulmonologist whose father died from IPF.

In addition, the Pulmonary Fibrosis Foundation is conducting the following activities later this year.
October 26Breathe Benefit 2013
Chicago, Illinois

December 5-7PFF Summit 2013: From Bench to Bedside
La Jolla, California

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Smartphone App Allows COPD Patients to Individualize Their Care.

Health-care technology advocates have long been preaching about the potential of smartphones and other types of disruptive technology to improve health-care delivery. We in organized medicine have been slow to answer the call. Studies that showcase the ability of these tools in major medical journals are rare.  However, in a recent issue of CHEST, we see a welcome addition to the medical literature.

In this study,  researchers taught patients with COPD to create daily symptom diaries on smartphones (BlackBerry 8700s).  The results were uploaded to a research server and the program alerted staff when certain predetermined criteria were met. Using the data, researchers were able to accurately and quickly identify patients who were having an exacerbation of their COPD. They were also able to collect data on both the timing and length of the exacerbation.

This has exciting implications. Perhaps this kind of patient centered  data could be used to identify patients with severe symptoms and prevent hospitalizations, or to serve as a measure of response in clinical trials to various interterventions. The possible applications are numerous.

Though there is one aspect of this study that, as a tech geek, leaves me ambivalent. Should I be excited that even an obsolete smartphone could prove to be so useful? Or depressed that even an obsolete smartphone is so far ahead of current medical technology?

How do you feel about patient-centered smartphone apps that allow patients to individualize their care?

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This article is also posted at the ACCP Thought Leaders Blog.

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The War Is Not Over: PTSD Common Among ICU Survivors.

The ICU is a terrifying place. The noise, the alarms, the invasive tubes and wires, and the loss of control all contribute to an overall feeling of anxiety and stress in patients and in families. Add to that the emotional burden of being ill or having a sick family member or friend, and you have a perfect storm for the development of post traumatic stress disorder.

As a health-care provider working in the ICU, it is easy to forget how desensitized we are to this environment. Recently, I took a phone call from my wife (who is a nonmedical professional) in the ICU. After a few minutes, she asked in a panicked voice, “Do you need to go get that alarm”?! And of course, it was a “first-level” alarm that I had completely tuned out and hadn’t even noticed. Looking around the ICU as I write this, I’m certain that I’m not the only one who is numb to these stimuli.

In a recent issue of CHEST, Dr. Bienvenu and colleagues report the findings of a study looking at posttraumatic stress disorder in the survivors of acute lung injury. They interviewed 60 survivors of acute lung injury 1 to 5 years after their hospitalizations. The authors compared a self-reported screening tool and a clinician-administered tool. They found that 27% of patients in this cohort had PTSD or partial PTSD, and that the self-reported screening tool was a reliable method of assessing PTSD in this population. This is promising, since a self-reported tool can gain more widespread use and may be able to help future investigators better determine factors associated with the development of PTSD in the ICU survivors.

Determining who would be likely to develop PTSD would be an important advance in critical care. Often I think we are surprised at how even our “good” outcomes can have long-standing functional problems following their ICU course. In the perfectly titled accompanying editorial Surviving the ICU Does Not Mean That the War Is Over, Dr. Schelling tells the story of one patient who survived extracorporeal membrane oxygenation (ECMO) only to report horrific memories of scenes from an apocalyptic warfare. These memories significantly impacted his quality of life and functional recovery, even though his overall outcome was “good.”

These studies add to the growing literature about the long-term effects of our treatments. I’d be eager to see more. We do not consider this important area of quality enough. With studies like this to help give us better tools, hopefully we will see more investigations into the long-term impacts of the life-saving therapies we provide.

Chris Carroll, MD, FCCP is a Pediatric Intensivist at Connecticut Children’s Medical Center, and my Social Media co-editor at Chest Journal. He is on twitter @ChrisCarrollMD. Be sure to check out our posts at the ACCP Thought Leaders Blog, where this article  was originally posted.

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What You Need to Know About Electronic Cigarettes

Electronic cigarettes are here, settling over the country, quite literally,  like a fine white fog.  Smokers in turn, have been turning to them as a tool to help them quit, though the device manufacturers are are not allowed to market them that way in U.S. It seems intuitive that a device that mimics the action of smoking but without the combustion and smell of burned nicotine would be an ideal nicotine replacement therapy. However, there remain precious little research about weather the fine white smoke they deliver is as harmless as a morning fog, or as dangerous (and unwatchable) as an Oregonian fog delivering the vengeance of tormented souls.

E-cigs’ popularity can be attributed to the fact that they deliver an experience that very closely mimics the act of smoking, minus the social banishment that comes with exhaling obnoxious smelling carcinogens into other people’s personal space. How do they accomplish this seemingly impossible task? Why through the magic of modern technology, of course!

E-cigs look much like a regular cigarette, they are puffed on in the same way, give off a vapor that looks like smoke and even have an LED light that mimics the combustion of nicotine. The devices are made up of several components. In place of the body of the traditional cigarette, there sits a rechargeable battery housed within a cartridge which is capped on its end by an LED light. Where the filter would usually be on a traditional cigarette, there sits  a heating element/atomizer as well as a replaceable nicotine cartridge. It is within this cartridge where a liquid mixture of nicotine, flavoring, and propylene glycol sits. Propylene glycol is a food additive that is also  used to create the “fog” in fog machines. The cartridges can be obtained in varying strengths of nicotine all the way down to zero.

When one puffs on an e-cig, the sensor activates the LED and the heating element which then atomizes the fluid in the cartridge, delivering a dose of nicotine and vapor. The main perceived safety advantage of this mode of nicotine delivery has presumed to be the lack of combustion of nicotine, which by itself creates a host of toxic chemicals. The nicotine itself is still delivered, however, with its resultant deleterious effects.

There remain a number of things which are not well known about e-cigs. While propylene glycol appears to be safe in other applications (it’s an FDA approved food additive), it is uncertain as to how inhaling it regularly affects the lungs.  It is also uncertain how efficacious e-cigs are when used the way that many people appear to be using them, as a smoking cessation tool.

To that end researchers in Italy conducted a study in which they enrolled 300 smokers who were not interested in quitting and were otherwise healthy. They were randomized to using e-cigs at either a steady dose of nicotine, a decreasing dose, or containing no nicotine at all for 12 weeks. They were allowed to use the e-cigs as they liked in addition to regular smoking and they were not  encouraged to quit smoking regular cigarettes.  After 1 year, quit rates (for all nicotine including e-cigs) among those using nicotine containing e-cigs were 11%. While this may not seem like a lot, it is as good as or better than most current nicotine replacement therapies. Keep in mind that these were people who were casually smoking e-cigs without the intention of quitting. Among those who did not quit, the number of cigarettes smoked daily decreased from 21 smoked per day to 14.

The investigators also looked at adverse events in order to gauge safety. They found that commonly reported adverse events actually decreased from baseline over the course of the study. They also found that side effects commonly seen during  smoking cessation trials such as hunger, insomnia, irritability and depression, were infrequent, nor were there any significant changes in weight.

This data appears encouraging that e-cigs do have some use as a nicotine replacement therapy, and that many people could actually quit without simply exchanging one addiction for another. It also appeared that, at least over the duration of the study, the e-cigs appeared safe. People appeared to have less side effects, probably owing to the fact that they were smoking fewer traditional cigarettes.

However, this short 12 week study can not tell us about long term effects of e-cigs. Nor does it address other pertinent questions. Such as the moral hazard of removing social stigmas. Many who use e-cigs do so with the thought that they can use them in places where regular smoking is not allowed.  One could wonder whether these products could take us back to the days of Don Draper,  when it was permissible to smoke in public places, or even on the job, unwittingly leading to greater smoking rates. Some argue that the ability to flavor e-cigs will further draw younger people to smoke, likely made worse by an incorrect perception that, since they are not cigarettes,  e-cigs are “safe”. Yet another problem is the consistency between products themselves. There exists a significant variation between contents of e-cigs between different makers, making it difficult to judge whether findings about one product can be generalized to others.

Indeed, we are only at the beginning of determining the risks and benefits of e-cigarettes. While they do appear to have some promise as cigarette smoking cessation tools, there remain several hazards to their increasing use. Until we have a better idea of what exactly is in this increasing fog, we best proceed with caution.

Citation: Caponnetto P, Campagna D, Cibella F, Morjaria JB, Caruso M, et al. (2013) EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as Tobacco Cigarettes A Prospective 12-Month Randomized Control Design Study. PLoS ONE 8(6): e66317. doi:10.1371/journal.pone.0066317

 

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