Author Archives: patricewendling

Where did all the disclosures go?

 

Each afternoon, the sound of bagpipes drifted through Chicago’s McCormick Place during this year’s Digestive Disease Week.

Pipes & Drums Chicago P.D., image by Wendling

The idea was for the Chicago Police Department’s Pipes & Drums  to serve as “pied pipers” to draw attention to the daily drawings for everything from a brand new Kindle to a free pass to next year’s DDW plus hotel accommodations, explained Rose Horcher, vice president of client services for the Chicago Convention and Tourism Bureau .

Since attendees had to get stickers from 10 different exhibitors before they could put their entry into the giant gold raffle drum, it seemed to have a lot more to do with drumming up exhibit attendance, but I won’t quibble.

The gimmick worked.

Each afternoon, attendees followed the pipers through the exhibit hall, weaving their way round the book stands, past the giant inflated green stomach exhibit and by the instrument table with signs reading “cheap” and “really cheap” scopes.  (Yes, they really said that.)

Some attendees struck a more patriotic note, requesting the National Anthem in honor of Team Six. Even jaded reporters were heard asking about the mysterious, midafternoon melodies.

As the meeting wore on, I couldn’t help but wish for a little assistance from the boys in blue in tracking down which of the very same exhibitors had a hand in the cutting-edge research I was hearing.

Meeting policy required that financial relationships for all individuals with the ability to affect the content of an educational activity be disclosed to the audience.

The financial disclosures were generated by Freeman AV and automatically displayed as the first slide for 6 seconds in the session room before going into the presentation, DDW program manager Crystal Young said in an interview.

I may have been the second to last kid in third grade to learn to tell time properly, but 6 seconds, it was not. Blink and those disclosures were gone.

Even more worrisome was that many of the presentations simply stated that while the lead author had no disclosures, the coauthors did. You just weren’t told what they were.

A line on the screen stated only: “Please visit www.ddw.org to view all DDW speaker disclosures.”

Any journalist worth their salt did just that, but what about the attendees?

Are they really going to go back home and dig up the disclosures before sharing what they’ve learned with their colleagues? The online resource certainly doesn’t make it easy. Coauthors have to be looked up individually by their last names since no single search by abstract number is possible.

Disclosing relevant financial relationships up front provides context for the potentially practice-changing data the physicians are about to hear. If an author or coauthor is an employee or board member of the study sponsor, the physician should know that. If the analyses were conducted by the device or drugmaker, that should be out there, too.

Image courtesy of Wikimedia in the public domain

 

 

Without it, the Pied Piper has a much better chance of leading us astray. 

By Patrice Wendling

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Seeing Red: Heart Disease and Women

The Red Dress Campaign has caught women’s attention regarding the very real dangers of cardiovascular disease, but a new study shows they may not be taking the message to heart.

Photo courtesy of The Heart Truth®, NHLBI, NIH

The study, presented at the recent American College of Cardiology meeting, found that the overall incidence of acute MI decreased among 315,246 patients admitted to New Jersey hospitals 1986-2007. The decrease was significant among both men and women, but was more prominent among men.

The incidence of acute MI fell from 598 to 311 per 100,000 men and from 321 to 197 per 100,000 women, according to cardiologist Dr. Liliana Cohen and her colleagues at the Robert Wood Johnson Medical School in New Brunswick, N.J. They also identified a growing gap in the rates of left heart catheterization and percutaneous coronary intervention between men and women.

The rates of catheterization increased fivefold in women and threefold in men over the 22-year study period, but the likelihood of catheterization remained lower for women. Moreover, the difference among male and female cath patients going on to receive PCI increased from 2.2% in 1986 to 9.4% in 2007.

Finally, both in-hospital and 1-year mortality remained higher among women, and failed to show a significant decrease after 2002 – the year the National Heart Lung and Blood Institute launched the Red Dress campaign.

“Although awareness of cardiovascular disease in women has increased in the general population, there has been much less translation of this into clinical practice,” Dr. Cohen told me.

This may be due to women presenting later because they doubt an MI can happen to them or that physicians still are not treating women as aggressively as they treat men, she said. It also may relate to the fact that women have more difficult cardiac anatomy, so that once they receive cardiac cath, PCI remains difficult.

Photo courtesy of The Heart Truth®, NHLBI, NIH

Dr. Cohen suggests that in its next phase, the campaign needs to continue to focus on public health awareness, but also on research into how to translate public awareness into clinical practice by focusing on physicians and into newer techniques of PCI for the smaller blood vessels in women.

Quibble if you will about the generalizability of data from a single state or the potential impact of a single PR campaign, but it’s hard to ignore these disappointing outcomes.

I once heard a bold and blistering guest lecture at a cancer meeting by Nancy Goodman Brinker, founder and CEO of Susan G. Komen for the Cure, who told several thousand — mostly male — oncologists that a survival rate topping 90% for early stage breast cancer simply wasn’t good enough.  Truer words were never spoken.

— Patrice Wendling

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Filed under Cardiovascular Medicine, IMNG, Internal Medicine, Surgery, Thoracic Surgery

Survival of the Abstinent Teen

Image courtesy of Wikimedia Creative Commons

Having a daughter who’s a “band nerd” may be music to a parent’s ear in more ways than one.

A new survey of 282 adolescent girls aged 12-21 reports that participation in band is significantly associated with current sexual abstinence.

The researchers came to the project with high hopes that potentially intervenable factors such as higher academic achievement, greater involvement in activities, and open family communication about sexual activity would be positively associated with abstinence.

That didn’t really play out, author and fourth-year medical student Kathryn Squires said at the recent meeting of the North American Society for Pediatric and Adolescent Gynecology.

There was no difference in GPA, involvement in sports, or most curricular and non-school-related activities between sexually active and abstinent teens.

Sexual activity, however, was associated with the typical risk factors of age of at least 18 years, having a job, having an increased number of boyfriends or an older recent boyfriend, and risky peer behaviors.

Positive influences on abstinence in all age groups were: participation in band, participation in school clubs, having abstinent friends, and personal and peer avoidance of alcohol and drugs, reported Ms. Squires and her colleagues at Washington University in St. Louis.

So what is it about band that helps adolescents elect to remain sexually abstinent?

Was the study group somehow unique? Not likely. When surveyed during 2008-2009 at a scheduled gynecologic visit with her parent present, 68% of participants reported being abstinent. This falls roughly in line with the 2009 Youth Risk Behavior Surveillance Survey, in which 46% of high school females reported ever being sexually active.

Is it the music? Not likely. Marching bands, like the one at the University of Michigan, are side-stepping the likes of John Philip Sousa today in favor of such hipsters as Lady Gaga.

Is it the geek factor?

“We had a lot of other what could probably be considered geeky things on there, like the newspaper, and those didn’t seem to make a difference,” Ms. Squires said. (I take umbrage at this remark, but then I grew up thinking Woodward & Bernstein were cool.)

“Maybe band is just more involved, but then sports are more involved too, as far as practices. So I don’t think it’s the time commitment.”

Having had any number of band nerds in our house over the years, I asked my two college daughters about the finding. After the giggling stopped, they suggested that band members, quite simply, are a very tight-knit group of kids. I wouldn’t assign a P value to this anecdotal info, but there’s something to be said for having a posse of friends to turn to when an adolescent considers taking that first step toward sex.

For physicians disinclined to advise parents to push their kids towards the tuba or trombone, Ms. Squires points out that ages 15-17 appear to be a critical period in which teens value their parents’ opinion the most, and it makes the most difference in delaying sexual initiation. “So that might be a good time for parental involvement or a medical intervention,” she said.

That said, I’m not so sure there’s ever a bad time for parental involvement, but then I didn’t ask my girls about that.

By Patrice Wendling

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Filed under Family Medicine, IMNG, Obstetrics and Gynecology, Pediatrics, Primary care

Fort Hood Shooting: A Cautionary Tale for Tucson

    I don’t care how many special news reports I see or read on the shootings in Tucson, I’m convinced we won’t fully understand what happened there for months, if ever. What we can be certain of is that more mass casualties will occur and that there will be missteps by both medical and journalism professionals.

I say this because of a recent post-mortem I heard on the November 2009 shootings at Fort Hood, where in a span of roughly 10 minutes, 32 people were injured and 10 died. Ultimately, 13 individuals lost their lives in that tragedy.

In the rush to report the news, two news helicopters hovered over the Scott & White Hospital, located 30 miles from Fort Hood, and the only level I trauma center in the area. The FAA was called in to clear the airspace, but not before the helicopters interfered with the transport of patients.

Back in Atlanta, CNN broadcast the Scott & White command center referral line, and over a 1-hour period, the hospital received 1,300 phone calls, which “essentially crippled our phone systems,” Dr. Jeff Wild, a surgical resident at that hospital, told his colleagues at the Western Surgical Association meeting.

The overload meant that Darnall Army Hospital in Fort Hood and nearby Metroplex Hospital, both of which were receiving shooting victims, couldn’t reach staff. Communication problems ultimately led to the transfer of two patients from Metroplex to an out-of-region hospital.

Triage was minimally organized and patients were maldistributed, with the closer facilities becoming saturated with shooting victims, he said. Darnall Army Hospital, a level III hospital, evaluated 27 patients and performed five operations on 4 patients, with one death. Scott & White prepared 6 trauma bays, made 16 of its 24 ORs available and posted one trauma surgeon in the OR and another in the ED, which proved invaluable in triaging patients, noted Dr. Wild. Over roughly a 2-hour period, they received 10 patients, of which five were taken urgently to the OR. Metroplex, which had only one emergency department physician and two general surgeons in the level IV facility at the time, received seven patients, including a civilian police officer who helped take down the perpetrator, and had no deaths. “I think we’re quite lucky that none of the patients transferred here had any adverse events,” he said.

I was beginning to squirm in my seat at this point, until Dr. Wild acknowledged the hospitals had alternative means of communication. The only problem was that personnel didn’t know how to properly work the radios and Web-based computer program.

Security was also an issue for the hospital. The alleged perpetrator, psychiatrist Maj. Nidal Hasan, was in the same ICU as six of his shooting victims and their families. The hospital elected to move Hasan to an isolated OR that served as his ICU until he was transported out of the hospital.

Since the shootings, Scott & White has hosted several disaster drills that included the army hospital, which had not been done before, Dr. Wild reported on behalf of senior author Dr. Randall Smith, Scott & White interim chief of trauma, critical and acute care surgery. Staff has been educated on various communication pathways, and twice a month, all the hospitals and EMS agencies in the area talk on the radios to make sure they’re working properly and that staff knows how to use them.

“Scott and White hospital has taken part in four mass casualty events in the past 25 years and, although these are considered somewhat a rarity, they seem to be more commonplace,” Dr. Wild said. “And if you haven’t already, it’s very likely a lot of you will take part in one of these events over your careers.”

From my own perspective, I just hope everyone knows the drill, including my colleagues at the mic.

  Patrice Wendling (on Twitter @pwendl)

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The Art of Medicine

There’s a great deal of art in the practice of medicine. It just doesn’t usually find its way into medical meetings.

Lilly Oncology On Canvas©

 Yet, there in the poster hall at the Chicago Multidisciplinary Symposium in Thoracic Oncology, amongst all the talk of TKI resistance and MEK inhibitors, were easels full of art including a pastel of mischievous fairies dancing among daisies and a painting of a bald woman smiling out from behind a pair of rose-colored spectacles beside the words, “Life is full of surprises.”  

The pieces are part of the Lilly Oncology On Canvas project, an art competition and exhibition launched in 2004 with the National Coalition for Cancer Survivorship as a way for those affected by cancer to express themselves and provide inspiration to others. The competition is open to patients, family members, friends, and caregivers and, surprisingly, health care providers.

"Best of Exhibition" 2010 Lilly Oncology On Canvas©

More than 600 entries were received for the 2010 competition, with Annette Zalewski , a nurse of nearly 30 years, earning three awards including “Best of Exhibition” for her determination to continue weaving together a beautiful life that was “cut up, rearranged” by lung cancer.
 
 This past year, previous winning pieces toured no less than 285 cancer centers, hospitals and cancer advocacy events from San Francisco and D.C. to such tiny towns as Opelousas, La., and Yankton, S.D. Some of the art and remains behind, with cancer charities also receiving up to $10,000 donated in the name of the winners.
RxArt project founder Diane Brown has decided to take the art concept one step further after a frightening CT exam left the former gallery owner and curator wishing for a diversion. Ms. Brown now coordinates with artists to place original installations in exam rooms and even splashes them across pricey diagnostic equipment. The result blows the typical hospital lobby floral landscape out of the water.
Even the stoic Scots have launched the Art in Hospitals project, which coordinates art exhibitions from the dialysis room to the psychiatric ward and offers workshops where patients can experiment creating their own art.
I can’t help but think all of this would please the 56-year-old retired physician turned pastel artist detailed in a case report just two aisles over in the poster hall from the Lilly Oncology On Canvas display.
The artist was diagnosed with squamous cell carcinoma of the lung, an uncommon pathology in a never-smoker. After four cycles of adjuvant chemotherapy, physicians at Mayo Clinic Arizona found no evidence of disease on her latest CT.
The authors note, however, that lung cancer in never-smoking women is the fastest growing subset of patients with lung cancer. Hopefully, these women’s journeys through cancer will be enriched with healthy doses of both medicine and art.

Patrice Wendling (on Twitter @pwendl)

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Going Postal

 What’s delivered by the U.S. Postal Service, but can’t fit into a letter or package?

The untold hope that a bone marrow match can bring to patients with leukemia, lymphoma and other life-threatening blood diseases.

Since holding its first drive in Baltimore in 1997, the Postal Service has become the largest contributor to the National Marrow Donor Program’s Be The Match Registry, adding more than 40,000 potential donors to the nonprofit registry.

Postal workers comprise the second largest civilian workforce in the country, and perhaps more importantly, one of its most diverse. Offering free tissue type-testing to its employees, their spouses and dependents is one way of harnessing that diversity and leveling the playing field for patients with blood diseases.

About 70% of patients do not have a donor in their family, and only 7% of potential donors on the national registry are African American, according to the NMDP.

In hopes of improving awareness, the NMDP has tapped larger-than-life basketball star Shaquille O’Neal , while its fundraising arm gave the Postal Service its first-ever “Rod Carew Award for Leadership” in recognition of saving more lives – 80 – than any other business organization in the country.

Not bad for a group of workers that have been the butt of jokes for years and frequently endure our ire this time of year.

Anyone interested in becoming a potential bone marrow or cord blood donor can contact the registry at: www.marrow.org.

Patrice Wendling (on Twitter @pwendl)

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Renaissance RSNA

This year’s meeting of the Radiologic Society of North America felt as foreign to the current American landscape as Harry Potter’s Hogwarts School of Witchcraft and Wizardry.

While politicians in Washington played hide-and-go-seek with desperately needed government funding and unemployment benefits,  rows and rows of glistening CT and MRI machines spanned the floor of Chicago’s McCormick Place. Physicians clutching cups of made-to-order espresso were wooed into private imaging suites created with elaborate screens and partitions. One was even shaped to resemble a pagoda, with an exquisite black and floral kimono inside.

“I believe one of the exhibitors said in a meeting that we had down here that they considered this the Renaissance RSNA, everything’s back solid and strong,” says RSNA assistant executive director Steve Drew.

When asked the dollar value of the equipment on display, Drew says they’ve never stopped to calculate it, but that $100 million would probably be a “very conservative guess.”

Exhibits have remained solid in terms of the amount of space being bought and the size of the booths, with about 700 exhibitors on hand this year, down slightly from an all-time high in the mid-700s.

“We feel good about it,” he says. “Based on information gathered through partnership meetings we have with our major exhibitors and market indicators, we had actually budgeted down 7% and we’re about even with where we were last year. So, depending on how you look at it, it’s almost a 7% increase.”

RSNA isn’t the only one feeling good about this year’s meeting.

The city of Chicago, which struggled this past year to retain its competitive edge in the convention trade, anticipates that the 6-day show will bring in $120 million, says Meghan Risch, director of public relations for the Chicago Convention and Tourism Bureau.

The economic impact of RSNA, arguably one of the biggest medical meetings in the world, has remained relatively constant, she contends, despite the economic downturn.

Attendance this year was about 57,500, according to unaudited attendance figures. Of these, 36,000 were professional registrants, defined as everyone but exhibitors and guests.

“We’re running about 4% ahead on professional attendance and the really good numbers there are the non-North American registrants, which came in at 36% of the professional registrants,” Mr. Drew says.

The average hotel stay for RSNA is five days – roughly double that for most medical meetings. Its international makeup is also probably the highest of Chicago conventions, according to Ms. Risch.

“International attendance is growing and RSNA is a great example,” she says.

–Patrice Wendling (on Twitter @pwendl)

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Recycling From the Heart

The concept of green living  takes on an entirely new meaning in light of new data showing that implantable cardioverter defibrillators (ICDs) can be removed and safely reused in other patients.

Dr. Behzad Pavri, an electrophysiologist at  Thomas Jefferson University in Philadelphia, and colleagues from across the United States, sent ICDs with at least 70% battery life to India where the devices were cleaned, sterilized, and re-implanted in 40 patients who were at risk of life-threatening arrhythmias, but could not afford the $25,000 price tag for a new device.

During 2 years of follow-up, 35% of patients received appropriate shocks from their ICDs, and no infections were observed, Dr. Pavri reported at the scientific sessions of the American Heart Association.

Five patients received a second recycled device, including one in as little as a year. While some may consider this an unacceptable life span for a device, Dr. Pavri pointed out that during the life of the first device the patient received as many as 50 life-saving shocks for a condition known as VF storm.

“I have stacks of letters from patients and from family members of these patients expressing their gratitude for having sent them what is basically our trash,” he said in an interview.

Dr. Pavri said the idea to recycle ICDs was hatched over a decade ago by physicians who wanted to provide the life-saving devices, earmarked for the trash or return to the manufacturer, to patients in need in their native countries. While the donated devices are removed for upgrade or infection, Dr. Pavri said he can foresee eventually reaching out to funeral homes for post-mortem device retrieval.

“I would like to see this effort grow, but I emphasis that it has to remain a charitable effort,” he said. “The moment it becomes commercially slanted, the purpose will have been defeated.”

Patients and physicians interested in donating a defibrillator can contact Dr. Pavri at behzad.pavri@jefferson.edu.

—Patrice Wendling (on Twitter @pwendl)

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Filed under Cardiovascular Medicine, Drug And Device Safety, Emergency Medicine, Family Medicine, Hospital and Critical Care Medicine, IMNG, Internal Medicine, Practice Trends, Primary care, Surgery, Thoracic Surgery

Family matters in cancer care

Family: can’t live with them, can’t live without them.

The upcoming holiday season calls the sanity of this adage into question, but when a member of the clan is diagnosed with cancer, there’s nothing like family to ease the way forward. Or is there?

 A team of Argentinian researchers evaluating the influence of family on the care of cancer patients found that 50% of physicians acknowledged at least one negative feeling for the relatives. Wrath, anger, rejection, and anguish were all noted, with women physicians more likely to feel anguish, and anger rising to the top of the list among male physicians. 

“Negative emotions must be considered since the above mentioned emotions may be an obstacle to the correct performance of the professional,” Luisina Ongania and colleagues reported at the European Society for Medical Oncology meeting in Milan. 

Before physicians cry foul, however, the survey showed that relatives had secrets of their own. 

"The Secret" by Edmund Blair Leighton, image in the public domain

 

 A stunning 95% of physicians said they had been asked by relatives to hide information of an adverse diagnosis or prognosis from the patient. 

Only 35% of the sample – made up of 50 oncologists, surgeons, pathologists, pulmonologists, and NIC providers – rejected this demand.  

Contrary to the image of women as chatterbox cream puffs, female physicians were more likely to snub a request for secrecy than men (40% vs. 32%), as were seasoned practitioners when compared with those with less than 10 years of clinical experience (40% vs. 32%). 

The influence of family can place doctors at an “ethical crossroads” in relation to respect for the patient’s autonomy, the researchers, from the Centro Médico Austral OMI in Buenos Aires, noted in their poster. 

Proponents of family centered care argue that engaging families in the hospital and even the ED can provide medical teams with valuable clinical and social information and calm patients who find themselves in a frightening and unfamiliar setting. Conversely, family members who witness the massive medical efforts launched to save their loved one are said to be more accepting of the outcome, even when the patient dies. (Click here for related story).

Exactly how hospitals, EDs, and clinicians should navigate these tricky waters is unclear, although all physicians in the survey argue that it’s important to receive information and training about how to work with relatives. Only 16% believed they’d received enough of this training.

Getting relatives to behave in the hospital, or even at the holiday dinner table, may be a harder nut to crack. 

By Patrice Wendling (on twitter @pwendl)

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Registry Homes In on Hydrocephalus

Treatment for pediatric hydrocephalus has not advanced substantially since the invention of cerebrospinal fluid shunts more than 50 years ago, in part because its relatively low prevalence has hampered research efforts.

 A 2005 white paper by the National Institutes of Health highlighted research priorities and called for multicenter collaboratives for data collection and longitudinal studies to assess natural history.

The Hydrocephalus Clinical Research Network  was subsequently launched and began enrolling children in April 2008 at a central data coordinating center and four research centers at high-volume pediatric hospitals in the U.S. and Canada. Six additional pediatric neurosurgery centers have recently applied to join.

 HCRN has six key research initiatives including reducing infections associated with shunt surgery, understanding the epidemiology and outcomes of endoscopic third ventriculostomy (ETV), and creating a detailed registry of all hydrocephalus patients at participating institutions.

At the recent Pediatric Hospital Medicine 2010 meeting, Dr. Tamara Simon shared some early HCRN data based on 1,384 children who had undergone 2,316 neurosurgical procedures.

Age (mean 7.1 years) and gender (55% male) were similar between HCRN centers, but there were differences in practice variation in initial procedures and management of intraventricular hemorrhage, said Dr. Simon, a hospitalist with Seattle Children’s Research Institute, a participating HCRN center.

 CSF shunts were used for primary procedures in an average of 86% of cases, with a range of 76% to 90%, while ETV, which is widely used in Europe, was utilized in 10% to 24% of cases depending on the center.

 CSF shunts and ETV work in opposite ways: Shunts drain the fluid from the ventricles in the brain to a site elsewhere in the body, while ETV uses a small hole made in the floor of the third ventricle to allow the CSF fluid to  bypass the obstruction and be reabsorbed in the brain’s sub arachnoid space.

 The Pediatric Health Information System (PHIS) has been collecting data on hydrocephalus for years, but it is hoped that the HCRN will focus specific attention on this life-threatening condition for which there is no cure. This may be a difficult task given the small numbers of patients, but money talks.

Each year in the U.S., pediatric hydrocephalus patients account for $1.4 to $2 billion in total hospital charges, but only 0.6% of admissions, Dr. Simon noted.

– Patrice Wendling (on Twitter @pwendl)

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