Category Archives: Family Medicine

Don’t Forget Travelers’ Health at the London Olympic Games

Photo courtesy of m.gifford (Flickr CC)

London may not be considered by everyone as exotic a locale as Beijing, but travel safety shouldn’t be overlooked across the pond. The CDC has several travel factsheets and resources for physicians and patients heading to the London Olympic Games, which start July 27  and run through Aug. 12.

Start by checking out Healthy Travel to the 2012 Olympic Games — the CDC’s rundown on basic health information for the UK, including a handy translation guide for UK health-related terms. If you’ve ever been curious about national healthcare, a mishap in London could answer a lot of questions.  Of course, so could an informational website developed by the UK’s National Health Service. The CDC also offers a link to travel tips from the U.S. State Department.

Wondering about the top travel advice for Americans headed to the games? Update your routine vaccines, including measles. “In 2011, some U.S. residents who traveled abroad got measles. When they returned to the U.S. they caused 17 measles outbreaks in various communities.” Probably the most important tip for a Yank in London: look both ways.  “Look right, look left, and look right again to avoid stepping into the path of traffic. In England, people drive on the left side of the road, not the right. Your safety is important. Road traffic is one of the leading causes of injury death to U.S. travelers in foreign countries.”

Kerri Wachter

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Preventing Youth Violence: Where’s the Research?

Photo courtesy of Thierry Geoffroy (Wikimedia CC)

Instead of focusing exclusively on risk factors for youth violence, it’s time to start looking at protective factors.  At least that’s what a CDC expert panel recommended in a special supplement of the American Journal of Preventive Medicine.

Homicide continues to be the second leading cause of death for youth aged15-24, and the leading cause of death for African American youth, according the CDC. More than 700,000 young people aged 10 to 24 were treated in emergency departments in 2010 for injuries sustained due to violence.

While identifying risk factors for teen violence is a necessary component of combating the problem, the experts recognize that it’s also important to identify factors that protect youth against youth embracing violence — such as resilience, positive youth development and community assets. “Most youth, even those living in high risk situations, are not violent and more must be learned about the factors that are helping youth, protecting them from engaging in violent behavior so that others can benefit,” the experts wrote in the supplement.

The CDC convened the Expert Panel on Protective Factors for Youth Violence Perpetration to clarify unresolved definitional and analytic issues on protective factors; review the state of evidence regarding the factors that appropriately can be labeled as direct protective, buffering protective, or both; carry out new analyses of major longitudinal surveys of youth to discover new knowledge about protective factors; an assessing the implications of research identifying protective factors for prevention programs, policies, and future research. This supplement presents the group’s work on direct protective factors — in particular identifying factors that exhibit mostly direct protective effects.

For more information about youth violence in the United States, check out a number of resources available on the CDC’s violence prevention Web page.

Kerri Wachter

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Counties Pursue Safer Drug Disposal

New programs to make it easier and safer for San Francisco Bay Area residents to get rid of unused medications are some of the first to try this on a large scale, and may serve as models for other cities and counties.

Since May 2012, a pilot program in San Francisco has allowed residents to drop off old medications at 13 pharmacies and 10 police stations (where controlled substances must be brought). San Francisco supervisors initially considered forcing drug companies to fund the program, and instead agreed to accept $110,000 from Genentech and the Pharmaceutical Research and Manufacturers of America to fund the program.

(Photo by J. Troha, courtesy of National Cancer Institute)

On July 24, supervisors in Alameda County (which includes East Bay cities such as Oakland and Berkeley) are likely to approve a Safe Drug Disposal Ordinance that would require drug companies to pay for disposal of their products or face fines of up to $1,000 per day, The Bay Citizen reports. Public agencies currently fund 25 drug disposal sites there, and the cash-strapped county wants the comparatively wealthy pharmaceutical industry to take more financial responsibility for the lifecycle of its products in order to reduce overdoses, accidental poisonings, and water pollution.

As we reported earlier this year, making prescription-drug “recycling” a cultural norm is one of five emerging public policies that could help the medical system keep opioids available while reducing the risk of addiction, abuse and accidental overdose, according to Keith N. Humphreys, Ph.D. Smaller versions have met with success, such as a drug take-back day organized by sheriffs in a small town in Arkansas (population 20,000) that brought in 25,000 pills, said Dr. Humphreys, acting director of the Center for Health Care Evaluation, Veterans Health Administration, Menlo Park, Calif., and a professor of psychiatry at Stanford University. He reports having no financial conflicts of interest on this issue.

Not everyone is happy with the idea. Trade associations for the pharmaceutical industry and biomedical companies argue that there’s no evidence that these programs will reduce poisonings, and they haven’t ruled out the possibility of suing to block the Alameda County ordinance, The Bay Citizen reports. The compromise that San Francisco reached for voluntary instead of mandatory funding from the pharmaceutical industry may be a middle ground.

In an era when government agencies have less and less money for public programs, it’s probably inevitable that they’ll pursue alternative financing for programs like this.

If your community has a drug disposal program, let us know how it’s working. Will these programs succeed, and will they reduce abuse, addiction, and accidental overdoses? We’ll keep an eye on this topic, and keep you posted.

–Sherry Boschert (@sherryboschert on Twitter)

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Physicians Grapple With Efficiency, ‘Do No Harm’

Two new books and a news article triangulate some interesting thoughts on improving efficiency in medicine while causing less harm to patients – and what that really means.

IMNG Medical Media reporter Alicia Ault’s feature story on “Can More Be Done with Less?” describes a recent conference on “Avoiding Avoidable Care” that brought medical experts together to strategize on how to avoid unnecessary tests and treatment, which can harm patients.

Dr. Vikas Saini, an organizer of the conference, told her that patients often demand tests or procedures because they seek certainty and want to know that the physician cares. But test results often lead to false knowledge, said Dr. Saini of the Lown Cardiovascular Research Foundation, which cosponsored the meeting. The key for physicians, he said, is to convincingly explain to patients why the test or procedure is or is not a good idea, and to practice evidence-based medicine.

To do that, though, requires an ability to interpret medical research and help patients understand it. That’s where Dr. Marya D. Zilberberg’s new book comes in. Between the Lines: Finding the Truth in Medical Literature is a breezy 170-page primer that spends most of the first half of the book cheerleading for scientific uncertainty. She also reviews the hierarchies of quality in research and touches on heterogeneity, biases, and a few general pitfalls in interpreting studies.

The second half of Between the Lines goes a little deeper in explaining study design, validity, statistical analyses, and more, though never so deeply that a nonstatistician’s eyes will glaze over. Dr. Zilberberg, a consultant, teacher, and blogger at Healthcare, Inc., explains these dry subjects in an eminently readable fashion.

I found it a valuable refresher (especially Part Two) even though I’ve been covering medical news for over two decades, and I imagine it would be a great introduction for the uninitiated. Dr. Kenneth W. Lin, a family physician who teaches a course in evidence-based medicine at Georgetown University, posted an online review that called Between the Lines “a rare book that bridges the gulf between medical publications and the real world of practicing clinicians.” Paul D. Simmons, Ph.D., who teaches family medicine residents in Louisville, Ky., said in an online review that he hopes incorporating the book will decrease the number of residents who finish his rotation thinking that evidence-based medicine is impractical, takes too much time, requires a Ph.D. in biostatistics, and doesn’t apply to their careers.

A separate book approaches these themes in ways that question medicine’s sometimes heavy-handed emphasis on “evidence” and “efficiency.” In God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine, Dr. Victoria Sweet eloquently recounts her 20 years of working at a chronic-care hospital for the ill and indigent (considered the “last almshouse in America”) as it morphs into a “modern healthcare treatment facility.”

Dr. Sweet’s scathing depictions of “efficiency” at the expense of time with patients bolster her call for “slow medicine” and the (missing) research to compare the two.

Disclosure: I’ve known Dr. Sweet for many years and even consider her a friend. I esteemed the book on its merits, and so did neurologist and author Dr. Oliver Sacks, whose book-jacket blurb called it, “A most important book, which raises fundamental questions about the nature of medicine in our time. It should be required reading.”

Dr. Abigail Zuger’s review in The New York Times began, “It is probably pointless to suggest that all the individuals presently shaping our health care future spend a quiet weekend with ‘God’s Hotel,’ Dr. Victoria Sweet’s transcendent testament to health care past. Who interrupts cowboys in the midst of a stampede? But if you’re one of the millions of doctors and patients out there choking on their dust, this is the book for you. Its compulsively readable chapters go down like restorative sips of cool water, and its hard-core subversion cheers like a shot of gin.”

The synchronicity of these three works is a sign of the times. As physicians are asked to do more with less, these writings help us understand what you’ve got to work with.

–Sherry Boschert (@sherryboschert on Twitter)

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Can HPV Vaccination Be Simplified?

The human papillomavirus vaccine was recommended for routine use in 11-12 year old girls in 2007. But by 2010, the most recent year for which data are available, less than half had received one dose of the three-dose series and fewer than a third had received all three. The inconvenience of the need for three separate office visits along with the vaccine’s price – about $130 per Gardasil dose, as of July 2011 – have certainly contributed to the low uptake.

©BVDC/Fotolia.com

Now, some parts of the world – including Mexico, Switzerland, and parts of Canada have moved to either a two-dose schedule, or a so-called “extended dose” schedule, in which the third dose is delayed until 5 years after the second one. (In the current U.S. three-dose schedule, doses two and three are given at 2 and 6 months, respectively, after dose one.)

“There has been emerging interest in HPV vaccine schedules with fewer than three doses, for a variety of reasons. These schedules could facilitate implementation, they may be more convenient for providers, parents, and vaccinees, and of course they would be cost-saving,” said Dr. Lauri Markowitz, of the Centers for Disease Control and Prevention, at a recent meeting of the CDC’s Advisory Committee on Immunization Practices.

No data on the efficacy of fewer than three doses have been published by either Merck or GlaxoSmithKline from their pivotal trials of Gardasil and Cervarix, respectively. But some other data are available for both vaccines. A nonrandomized study in Costa Rica that included more than 1,100 women who had received just one or two doses of Cervarix suggested that two doses or maybe even just one – could be as protective as three doses against infection at 4 years.

And in an as-yet unpublished study done in Canada, immune responses against both HPV 16 and 18 at 3 years were similar between two doses of Gardasil given at age 9-13 years and three doses given at age 16-26 years. But, there are limited efficacy data and no long-term data, Dr. Markowitz said.

Electron micrograph of human papillomavirus (HPV) / Courtesy of the National Cancer Institute

In an e-mail, Deb Wambold of Merck Vaccines said that, while the company does support studies of alternative dosing schedules for HPV vaccination including two-dose regimens, so far those studies are “interesting preliminary explorations in select subpopulations of vaccinees,” and “It is important to note that there are no data on the clinical efficacy or durability of effectiveness with two doses of either of the HPV vaccines, as we have for the recommended three-dose vaccination regimen.”

Dr. Joseph A. Bocchini Jr., who chairs the ACIP HPV vaccine working group, concurred. In an interview at the ACIP meeting, he noted that the long-term efficacy of two doses is “worth looking at,” as is the varying of three-dose schedules. “But, at this point, there are too few data to apply this to recommendations in the United States.”

More data from ongoing trials will be available in the next few years, Dr. Markowitz said.

-Miriam E. Tucker (@MiriamETucker on Twitter)

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“Turning the Tide” on HIV/AIDS

In advance of the upcoming XIX International AIDS Conference, the International AIDS Society and the University of California, San Francisco, have issued the “Washington D.C. Declaration,” a nine-point action plan aimed at broadening global support for “Turning the Tide” of the AIDS epidemic.

Everyone is urged to sign the Declaration.

It calls for:

1) An increase in targeted new investments;
2) Evidence-based HIV prevention, treatment, and care in accord with the human rights of those at greatest risk and in greatest need;
3) An end to stigma, discrimination, legal sanctions, and human rights abuses against those living with and at risk for HIV;
4) Marked increases in HIV testing, counseling, and linkages to services;
5) Treatment for all pregnant and nursing women living with HIV and an end to perinatal transmission;
6) Expanded access to antiretroviral treatment for all in need;
7) Identification, diagnosis, and treatment of tuberculosis;
8) Accelerated research on new tools for HIV prevention, treatment, vaccines, and a cure;
9) Mobilization and meaningful involvement of affected communities.

Turning the Tide is the theme of this year’s biennial conference, which will take place July 22-27 in Washington.  It is expected to draw 25,000 attendees, including HIV professionals, activists, politicians, and celebrities. Sir Elton John will open the conference and Bill Clinton will close it. A large delegation of U.S. members of Congress will participate, and Bill Gates will moderate a session. An enormous “Global Village” outside the D.C. Convention Center will be open to the public. “If you haven’t been, it’s a conference like no other,” conference cochair Dr. Diane V. Havlir said at a press briefing.

The recent optimism regarding HIV/AIDS stems from major advances in knowledge regarding prevention of partner transmission with early patient treatment, pre-exposure prophylaxis, and male circumcision as HIV infection prevention (new data will be released at the meeting), all of which are viewed as breakthroughs  in the fight against HIV/AIDS. “So we have now in our hands the tools. The question is how do we combine those tools together, and how do we roll them out,” said Dr. Havlir, professor of medicine at the University of California, San Francisco, and chief of the HIV/AIDS division at San Francisco General Hospital.

Dr. Diane V. Havlir / Photo by Miriam E. Tucker

Monday’s plenary session will include an address from Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, on “Ending the HIV Epidemic: From Scientific Advances to Public Health Implementation.” Other plenary topics during the week will include viral eradication, vaccines, TB and HIV, and HIV/AIDS in specific populations including minorities, women, youth, and men who have sex with men. On Friday, there will be a plenary talk that may be of particular interest to the primary care community, “The Intersection of Noncommunicable Diseases and Aging in HIV.”

Plenaries and other conference sessions will be webcast at http://globalhealth.kff.org/aids2012.

-Miriam E. Tucker (@MiriamETucker on Twitter)

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VA Adopts Innovative Project Nationwide

An innovative medical project that we reported in April has made the big time — a nationwide pilot program in the immense Department of Veterans Affairs system, the nation’s largest integrated health care system.

Project ECHO (Extension for Community Healthcare Outcomes) has been working wonders in New Mexico, Washington State, and a few other locations to bring specialty care to thousands of people who previously had little access to this care. Created by Dr. Sanjeev Arora of the University of New Mexico, Project ECHO connects primary care physicians with specialists in weekly case-management and educational teleconferences to give primary care physicians the support they need to manage complex patients with hepatitis C, asthma, chronic pain, rheumatic or cardiac disease, HIV, substance abuse, mental illness, high-risk pregnancy, childhood obesity, and more.

Dr. Arora (center, back turned) leads a Project ECHO videoconference. (Courtesy Project ECHO)

The U.S. Department of Health and Human Services awarded Project ECHO an $8.5 million Health Care Innovation grant in May 2012 to expand its operations in two states.

Impressed, the Department of Veterans Affairs cloned Project ECHO and tomorrow will launch a nationwide pilot program in the VA system that could help veterans get care in the local communities instead of traveling to specialists for treatment of heart failure, chronic pain, hepatitis C, etc. In our April 2012 video interview with Dr. Rollin M. Gallagher, deputy national program director for pain management in the Veterans Health Administration, he explains why Project ECHO is so appealing to the VA

The VA’s version, called Specialty Care Access Network-ECHO (or SCAN-ECHO), will kick off officially with a briefing by a panel of experts in Washington, D.C., that also can be viewed by Webcast (how appropriate) on Wednesday, July 11, 2012 from 10 a.m. to 11:30 a.m. Eastern time. Register here to view the Webcast.

The panel will feature Dr. Arora with Dr. Robert A. Pretzel, under-secretary for health in the V.A. system, Dr. John R. Lumpkin, director of the Health Care Group for the Robert Wood Johnson Foundation, which has funded much of Project ECHO’s work, and both specialty and primary care providers from the Cleveland VA Medical Center.

With any luck, the success of Project ECHO will echo across the country as this model of care expands.

–Sherry Boschert (@sherryboschert on Twitter)

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Title IX Hits 40

Image courtesy of Sarah Jones via Wikimedia Commons (CC)

What does Title IX mean to you? Athletics is typically high up on the list for many people. Title IX has played an important role in getting girls and young women onto the field. On the 40th anniversary of the landmark gender equity in education legislation, U.S. Secretary of Education Arne Duncan noted in a speech, “when Title IX was enacted in 1972, less than 30,000 female students participated in sports and recreational programs at NCAA member institutions nationwide. Today, that number has increased nearly six-fold. And at the high school level, the number of girls participating in athletics has increased ten-fold since 1972, to three million girls today.”

In an era of nationwide public health concerns over childhood obesity, getting girls and young women involved in sports becomes even more important. However, Title IX’s expansion of school-based athletics programs has more far-reaching benefits as well. As Secretary Duncan pointed out, female athletes “are more likely to graduate from college than female students who don’t play sports.” Female athletes are also less likely to use drugs and become pregnant as teenagers.

Sports are only part of the Title IX picture though. In fact, neither the word “sports” nor “athletics” are used in the text of the legislation. The law has changed the academic landscape for female students.

U.S. Navy photo by Greg Vojtko (Public Domain)

Here’s a few things that you might not know:

  • 57% of students in postsecondary education in 2009-2010 were women; women also accounted for 62.6% of students receiving a master’s degree.
  • Since 1976, girls enrolled in gifted and talented education programs have outnumbered boys enrolled. In 2009, 8.1% of girls participated in gifted and talented education programs, compared to 7.4% of boys.
  • A greater percentage of the girls in 7th or 8th grade (20%) are taking Algebra I, compared with boys (18%).
  • Girls are evenly represented in biology and outnumber boys in chemistry, but are underrepresented in physics.

Welcome to middle age, Title IX. Let’s see what else you can do to get girls on the field and in the classroom.

Kerri Wachter

Data from the “Gender Equity in Education A Data Snapshot” by the U.S. Department of Education’s Civil Rights Data Collection.

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New Anti-Inflammatory Drugs Will End Anti-TNF Dominance

Tumor necrosis factor inhibitor drugs began to dominate treatment of inflammatory diseases like rheumatoid arthritis, psoriasis, and the inflammatory bowel diseases ulcerative colitis and Crohn’s disease a little over a decade again. Now, the time when the importance of the anti-TNFs will wane and newer drugs will take their place is clearly visible on the horizon. It hasn’t happened yet, but the era of anti-TNF dominance for treating inflammatory diseases that persisted throughout the 2000s will end in the next 5 years.

The anti-TNF era began in 1998 with the approval of etanercept (Enbrel) for rheumatoid arthritis and infliximab (Remicade) to treat Crohn’s disease. In subsequent years, the list of approved anti-TNFs expanded to include adalimumab (Humira), golimumab (Simponi), and certolizumab (Cimzia), and the approved indications grew to include many inflammatory disease of joints, the GI tract, and skin. The anti-TNFs revolutionized inflammatory disease treatment and made treatment to remission possible for many patients.

tumor necrosis factor (green, purple, black) and TNF receptors (blue)/courtesy Bassil Dahiyat; Science

But reports from just the past month show that new agents are overtaking the anti-TNFs.

In May, I reported from Digestive Disease Week on phase III trial results with vedolizumab, which was compared against placebo for patients with ulcerative colitis. One of the study investigators noted that vedolizumab beat the placebo arm for steroid-free clinical remission by 30 percentage points. “Nothing else is that good,” Dr. William Sandborn, professor of medicine and chief of gastroenterology at the University of California, San Diego, told me, and the benchmark he had in mind was the performance of the anti-TNFs in similar patients.

More recently, at the European Congress of Rheumatology earlier this month I heard a report on a head-to-head comparison of the anti-IL-6 drug tocilizumab (Actemra) and the anti-TNF adalimumab in patients with rheumatoid arthritis. After 24 weeks of monotherapy, patients on tocilizumab had nearly a fourfold higher remission rate than patients on adalimumab. Though the monotherapy trial design did not mimic the way most rheumatoid arthritis patients get treated, the new drug tocilizumab absolutely blew adalimumab out of the water in a rare head-to-head comparison among different classes of anti-inflammatory drugs.

And at the same meeting several talks highlighted another new anti-inflammatory class of agents coming soon to the U.S. market, the Janus kinase (JAK) inhibitors, such as tofacitinib, which is expected to received FDA approval later this summer. Phase III results show that tofacitinib has safety and efficacy that seems at least comparable to anti-TNF drugs, with the advantage of oral dosing.

Vedolizumab, tocilizumab, and tofacitinib are just the tip of new waves of anti-inflammatory drugs that will soon substantially alter a landscape that the anti-TNFs have mostly had to themselves for the past 14 years. For the moment, the anti-TNFs have the advantage of a longer track record for safety, but changing that is only a matter of time.

—Mitchel Zoler (on Twitter “mitchelzoler)

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IUD Contraception Cost May Inhibit Use

A copper intrauterine device (IUD) retails for the equivalent of $20 in France. In the United States, it costs $860, Dr. Eve Espey says.

“This is highway robbery. It has to change,” she said during a talk on long-acting reversible contraception at the annual meeting of the American College of Obstetricians and Gynecologists (ACOG). “Honestly,” she sighed, “If you went to Home Depot and picked up the supplies to make yourself an IUD, what would it cost? Like, under $1.” (Not that she’s advocating that.)

Dr. Eve Espey (Sherry Boschert/IMNG Medical Media)

Strong words, and they’re not coming from just any frustrated physician. Dr. Espey is chair of ACOG’s Working Group on Long-Acting Reversible Contraception and a professor of ob.gyn. at the University of New Mexico, Albuquerque.

The high U.S. price may be one reason that only 6% of U.S. women using contraceptives choose an IUD, even though studies show it’s one of the most effective kinds of contraception, along with levonorgestrel intrauterine systems and contraceptive implants, the other two kinds of long-active reversible contraceptives.

Sure, the cost of a copper IUD may be somewhat less than $860 if the physician or patient has access to government prices or other discounts, but it still creates a financial burden for physicians to stock their shelves with IUDs, not to mention inadequate reimbursement from insurers, she said.

“I think that the emerging, biggest barrier to IUD and implant use in this country is price,” Dr. Espey said. “ACOG is really trying to work to make a dent in that, but I think that until we see a cheaper IUD, it’s going to be a barrier to increased usage.”

Dr. Espey reported having no financial disclosures.

There’s only one copper IUD approved for use in the United States, so I contacted the makers of the ParaGard IUD, Teva Women’s Health. The “typical cost” for one ParaGard is $754, according to the company’s vice president for corporate communications, Denise Bradley. She said that the ParaGard’s price is “below most other forms of female birth control,” that most insurance plans cover ParaGard, and that the company offers women whose insurers don’t cover the IUD the option of paying by monthly installments.

She didn’t respond directly to the question of whether ParaGard’s cost is a barrier to use, but said, “Teva Women’s Health believes that increased access to all forms of contraception is of critical importance to all women of reproductive age.” She declined to comment on price differences between copper IUDs in the United States and other countries.

Recent data show that when financial barriers are removed and women receive standardized information about contraceptive choices, many more choose long-acting reversible contraception. The Reproductive CHOICE Project recruited nearly 10,000 women in the St. Louis area who desired contraception, gave them standardized counseling, and provided contraceptives for free.

A copper IUD. (Photo courtesy flickr/+mara/Creative Commons)

Results from the first 4,167 women to complete a year of follow-up found that 71% chose a long-acting reversible contraceptive (45% the levonorgestrel intrauterine system, 13% the copper IUD, and 13% an implant), Dr. Espey said. Others chose contraceptive pills, vaginal rings, transdermal patches, or another method.

After 12 months of use, 80% of IUD users reported being somewhat or very satisfied, compared with 54% of pill, patch, or ring users, she said. Only 55% of pill, patch, or ring users were on the same choice of contraception after 1 year compared with 84% of IUD users, 83% of implant users, and 88% of women who got a levonorgestrel intrauterine system.

The investigators recently reported that there have been 334 unintended pregnancies in 7,486 participants. Those using the pill, patch or ring were 22 times more likely to experience contraceptive failure compared with participants on long-acting reversible contraceptives (N. Engl. J. Med. 2012:366:1998-2007).

Long-acting reversible contraception was equally effective in all age groups, but use of the pill, patch, or ring was strikingly less effective in participants younger than 21 years, who were nearly twice as likely to have an unintended pregnancy compared with older women using those same methods of birth control.

–Sherry Boschert (on Twitter @sherryboschert)

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