Practical Pointers - September 2005

1) The Highlights section contains brief comments patterned after the “abstract” placed on the first page of many studies reported in journals. Highlights condenses the content of studies, and allows a quick review of pertinent points of each article.

The Editorial Comments are the editor’s assessments of the clinical practicality of articles based on his long-term review of the current literature and his 20-year publication of Practical Pointers.

2) The main Abstracts section is designed as a reference. It presents structured summaries of the content of articles in much more detail.

An Index containing all the Highlights is published twice a year. In an evening or two, the reader can refresh memory of the entire content of practical points abstracted from 6 major journals over the 6-month period.

I hope you will find Practical Pointers interesting and helpful. The complete content of all issues for the past 5 years can be accessed at www.practicalpointers.org

Richard T. James Jr, M.D.

Editor/Publisher.

HIGHLIGHTS AND EDITORIAL COMMENTS SEPTEMBER 2005

9-1 “THE MEDICAL HUMANITIES”, For Lack Of A Better Term

So, what are “The medical humanities” anyway?

The commentator (an established poet and essayist) finds it very difficult to define.

We know intuitively that the way medicine is now taught and practiced is simply wrong—that the humane is being supplanted by unfeeling science and uncaring economics. The medical literature describes the practice of medicine in the modern era as increasingly dominated by economic constraints and technological hubris.

Medicine, in losing sight of how the arts and humanities inform and elevate the work of healing, is following the footsteps of larger societal trends.

“Distancing” is the process whereby physicians remove themselves from the particulars of patients’ experiences of illness so that they may render accurate diagnosis and treatment. It imperils the work of doctoring, and has converted it from a sacred vocation, borne of a desire and duty to alleviate suffering, into a mere financially rewarded, technically challenging line of work.

The view of any kind of work as simply a means to the all-important paycheck is widespread nowadays. “Distancing” pervades most human interactions.

Perhaps it is expedient to blame the shortcomings of modern biomedicine on the stereotypically bespectacled, heartless philistine hiding behind his bleeping machines in his white coat, rather than to look more critically at the economic pressures that have so harshly changed medical practice. Can we really expect beleaguered clinicians and medical educators to teach ethical thinking or to nurture compassion in trainees who come to their prospective profession lacking in these fundamental personal virtues that more appropriately ought to have been instilled in them by their parents, or by immersion in what should be a healthier, more universally humane society?

Only with omnipresent and immediately accessible humanities resources for ourselves and our trainees can we nourish in our profession “the art of medicine’ from which we have become so estranged.

I do not agree that medical care is being” dehumanized”. I do not agree that unfeeling science and uncaring economics are supplanting the “humane” in medicine.

In my view, the editorialist’s criticism is much too harsh. I do not believe that physicians are less “humane” (ie, less caring; less empathetic) than they were in the 18^th, 19^th and 20^th centuries. Many health care practitioners simply do not have the opportunity to establish an empathetic relation with patients. It takes time to develop a “connection”. They are much more involved in the difficult task of providing the best of evidence-based medicine and technology. (Little of evidence-based medicine and present day technology existed before the mid-1900s.) They nevertheless retain a desire and duty to alleviate suffering, and they do indeed alleviate suffering. They are “humane” in a new and different way.

Conscientiously applying the best of modern therapy and diagnosis to each patient is an expression of caring ( “humaneness”). Expert use of a blinking machine, which will often benefit patients’ health and increase longevity, is an important part of caring. I doubt many patients (including the editorialist) would be willing to exchange the miracles of modern medicine, surgery, imaging, and anesthesia in favor of a more consistent and personal “caring” connection with every health-care provider.

Caring and technology are not mutually exclusive. Primary care clinicians are blessed with the opportunity to combine the two. They care for patients and families over time. This provides opportunity to connect and give support to the cares and concerns of their patients; to elicit , understand, and respond to each patient’s “story” in addition to attending the presenting complaint.

Has the practice of medicine been “converted into a mere financially rewarding line of work”? Not by a long shot. I do not believe young aspiring physicians enter the profession for the purpose of making money.

Nowadays, in contrast to the past, maintaining an office staff is costly. Technology is expensive. I doubt the income of the average physician, especially primary care clinicians, exceeds that of other professions. Few become “rich” as a result of their medical practice. But, it is important to earn enough to provide the family with a comfortable, safe home, a good education, and to save for retirement. This is also a form of “caring”.

Many physicians give generously of their income to charitable organizations and church. Many express humaneness by pro-bono work, caring for the less fortunate in one of the many free clinics scattered throughout the country.

The healing professions do not lack humaneness. The way it is expressed has changed.

9-2 “THE MEDICAL HUMANITIES”: Attempting A Definition

“A Humanity” is any product of human creativity and any human relationship which promotes understanding, kindness, good will, compassion, care, and caring.

“The Humanities” is the totality of all “A Humanity”.

“A Medical Humanity” (“The Medical Humanities”) does not differ from any other. However, medical professionals (nurses, therapists, dieticians, and physicians) may have more opportunity to express ”A Humanity” because they care for others when the others are most vulnerable.

“Doing It In The Doctor’s Waiting Room May Be Better Than Doing It At Home.”

9-3 SELF MONITORING OF HIGH BLOOD PRESSURE

This issue of BMJ reports a randomized trialon self monitoring BP in the physician’s office The self measured and the professionally measured BPs were comparable. This suggests that hypertension guidelines are applicable to self monitoring.

Patients were welcomed into the BP measuring room of the practice and encouraged to measure their own BP at least once a month using an electronic BP machine. They received instructions on how to use the machine on their first visit. Patients were given an instruction card showing their BP target (140/85). Monthly BP readings were recorded on the card. Patients were asked to see the practitioner or nurse if BP exceeded target on successive months, or if it was very high. More than 90% of patients were seen by the medical staff during the year.

This is a switch from the usual studies on self monitoring BP at home.

I wonder if some primary care clinicians would be tempted to place a validated electronic device in an alcove of the waiting room allowing any patients who are waiting to measure their BP. I believe this would be more meaningful and accurate than self measuring in a drug store.

9-4 THE METABOLIC SYNDROME—A New Worldwide Definition

The ultimate importance of the MS is that it identifies individuals at high risk for type 2 diabetes (DM2) and cardiovascular disease (CVD).

The International Diabetes Federation (2004) felt there was a strong need for one practical definition that would be useful in any country for the identification of high risk of DM2 and CVD:

1) Central (abdominal) obesity is a prerequisite to the diagnosis of the MS.

Waist circumference 94 cm or more for white men of European origin; 80 cm or more for women. (The cut points for other ethnic groups have been changed (See text). In the USA, cut points of 100 cm and 88 cm are likely to be retained in the definition.

Central obesity is related to each of the other components of the MS. If it is not present, the MS is not diagnosed.

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Plus any two of the following four factors:

2) Triglycerides 150 mg/dL and above.

3) HDL-cholesterol under 40 mg/dL in man and under 50 mg in women.

Both 2) and 3) are commonly observed in patients with DM2 and insulin resistance.

Both are risk factors for CVD.

4) BP 130 systolic and above; diastolic 85 and above, or previously treated hypertension.

5) Fasting blood glucose 100 and above, or previously diagnosed diabetes.

If above 100, a glucose tolerance test is strongly recommended.

Note that persons with 2), 3), 4) and 5) who do not have abdominal obesity are not defined as having the MS. Nevertheless, they are at increased risk. Not all 5 factors carry the same weight. But, the more factors present, the higher the risk. Of course, the other factors should be determined and treated.

I would wager that most men over age 50 in the USA have an abdominal girth over 100 cm (40 inches). And that men with obvious abdominal obesity have the MS.

It would be reasonable to immediately recommend life-style changes for them. Indeed, the need for lifestyle changes in the USA is universal.

I garnered some details from the web site of the IDF.

http://www.idf.org/webdata/docs/Metac_syndrome_def.pdf

The Big Question—Will It Mutate To Facilitate Human-To-Human Transmission?

9-5 INFLUENZA A (“Bird Flu”; H5N1): Will It Become The Next Pandemic Influenza? Are We Ready?

Experts have predicted a next pandemic flu for many years. They believe that the question is not whether another pandemic will occur, but when. They fear an event like the Spanish flu of 1918-19 (H1N1) which rapidly caused death of millions and reduced the average life expectancy in the USA by 13 years. The 1918-19 pandemic affected mostly young, previously healthy adults. Death occurred within a week due to a hemorrhagic, necrotizing, viral (not bacterial) pneumonia.

Avian influenza (influenza A H5N1) appears to have a similar potential.

Most flu viruses occur in birds. Aquatic waterfowl are their natural reservoir. Only a few types of the virus have circulated widely in humans. “Bird flu” refers to both influenza in birds and to instances when the virus jumps the species barrier to cause human disease.

To cause a global pandemic the virus needs three properties: 1) ability to infect people, 2) substantially new antigenic properties to which humans are not immune, and 3) efficient person-to-person transmission. H5N1 has the first 2 properties, but there is only minimal evidence of 3).

Amantadine and rimantadine are not active against H5N1 even though it is a type A virus. Oseltamivir (Tamiflu; given orally) and zanamivir (Relenza; given by inhalation) are active in vitro and in animal models. Clinical utility for treatment and prevention of H5N1 has not been rigorously studied. The supply is inadequate for a global pandemic. Antiviral resistance does occur.

What about drug treatment and prophylaxis? Early administration of antiviral agents appears to be beneficial. Patients with suspected H5N1 should promptly receive a neuraminidase inhibitor pending diagnosis by laboratory testing. The optimal dose and duration of treatment are uncertain. Currently approved regimens likely represent the minimum required. High levels of resistance to Tamiflu have been detected in several patients with H5N1. Amantadine and rimantadine are not effective for H5N1. For prophylaxis, Tamiflu is warranted for persons who have had a possible exposure to H5N1.

Current supplies of Tamiflu and Relenza are grossly insufficient for prophylaxis and treatment of H5N1. Those of us who are knowledgeable about H5N1 and affluent enough to afford Tamiflu may be tempted to purchase and hoard a supply for possible use. There are serious objections to this. The limited supply should be reserved for treatment of individuals who are infected with the flu virus. “Ring” prophylaxis may be a reasonable control measure. This involves quarantine and prophylactic drug therapy of individuals (eg, family; health care workers) in close contact with a patient with proven influenza. This may reduce likelihood of spread in the community.

The North Carolina Department of Health has issued a statement strongly discouraging personal stockpiling of Tamiflu. It points out: 1) There has been no sustained human-to-human transmission in Asia; 2) There is no H5N1 in the USA. No poultry have been infected; 3) Supplies are limited and should be reserved for people who will need it for prevention of regular influenza this season; 4) If a pandemic occurs, Tamiflu should be used by priority groups rather than for personal stockpiles; 5) Inappropriate use may led to resistance.

“Cutting Down” Reduces Risk Of Lung Cancer, But Not Risk Of Myocardial Infarction And COPD.

9-6 EFFECT OF SMOKING REDUCTION ON LUNG CANCER RISK

This study asks - Would “cutting down” reduce risk of LC?

Divided into 6 groups according to smoking habits:

1) Continued heavy smokers (> 15 cigarettes daily; mean = 20).

2) Reducers reduced smoking from > 15 per day by a minimum of 50% without quitting.

3) Continued light smokers (1-14 per day).

4) Quitters (stopped between 1^st and 2^nd examinations).

5) Stable ex-smokers.

6) Never smokers.

Groups: 1) 2) 3) 4) 5) 6)

Number 7351 832 3199 1355 2881 4066

Pack years at baseline 31 27 14 19 14

Number of LCs 576 52 104 52 52 28

% with LC 7.8 6.3 3.3 3.6 1,8 0.7

Adjusted hazard ratio for LC: 1.00 0.73 0.44 0.50 0.17 0.09

Absolute difference, continued heavy smokers vs those who reduced consumption by 50% = 7.8% - 6.3% = 1.5%. Sixty two smokers would have to cut consumption by 50% to prevent one LC. Twenty four would have to quit completely to prevent one LC.

The authors previously investigated the all-cause mortality, fatal and non-fatal myocardial infarction, and

hospitalization for COPD in smokers. They found no reduction in risk associated with smoking reduction. “Cutting down” does not reduce these risks. LC is more likely to demonstrate a dose-response to cutting down.

See the following report on snuff. RTJ

Would You Advise Snuff For Nicotine Replacement?

9-7 MIXED FEELINGS ON SNUS

The British American Tobacco (BAT) company markets “snus” in Sweden. “Snus” is a finely ground snuff that is pasteurized to diminish the carcinogenic nitrosamines sometime found in high levels in snuff as well as in cigarettes. (The sale of snus is illegal in the European Union except in Sweden.)

BAT is trying to….”extend the appeal of snus to more adults smokers who have not heard of snus to try it.” BAT claims that the move is part of their “continuing efforts in harm reduction”. They claimed that the biggest group of quitters in Sweden used snus as “the main aid in quitting”.

Is it true that snus is a harm-reduction product? It certainly is much less harmful than cigarettes. It has not been associated with any increase in lung cancer. But, it is classified as a carcinogen by the International Agency for Research on Cancer. A recent study reported an increased risk of pancreatic cancer. Snus is not harmless.

Is it effective as an aid to quitting cigarettes? Evidence is inadequate, but suggests that it may be effective for some smokers. Many nicotine users favor it over tobacco smoke. The fact that more Swedes choose snus rather than therapeutic nicotine replacement for routine use suggests that it offers a better “fix”.

Is it addictive? This is controversial. Nicotine replacement therapy is relatively non-addictive, but there is a view that, if such therapy is to replace cigarettes it needs to be more competitive, and this means more addictive.

It is possible (however reluctantly) to agree that snus is a harm-reduction product, but only when compared with cigarettes.

In view of the ban on cigarettes in many restaurants and bars, tobacco companies are encouraging smokers to try snuff as an alternative where smoking is forbidden. Is this ethical?

I abstracted this article to ask myself—if my patient stated he had absolutely no intention of quitting, or was unable to quit after many tries, would I suggest his switching to snuff? (Snuff in the USA is probably more carcinogenic than snus.) Would I suggest snuff as a drug (nicotine replacement) hoping to enable cessation, or at least a reduction in cigarette smoking?

We accept risk with every drug we prescribe. With preventive therapy, (eg, aspirin, statin drugs; antihypertension drugs) patients seem quite willing to accept the risks. I abstracted this article to ask—should we consider snuff a preventive drug (ie, one that reduces risk)? Would the patient sue if he developed oral cancer after being informed of the risk and accepting it?

I would merely point this article out to the patient and let him decide on his own. I would not prescribe snuff. Indeed, I would place in the record that I advise cessation of all tobacco products.

9-8 SCABIES: Diagnosis And Treatment

Eight clinical points.

“Suicide Headache”

9-9 CLUSTER HEADACHE

Cluster headache (CH) is one of the most severe pain syndromes. It is underdiagnosed and suboptimally managed in primary care. It has substantial effects on functioning, even when appropriate treatments are used.

Headaches often start about 1 to 2 hours after falling asleep, or in the early morning. Attacks can strike up to 8 times a day, are relatively short-lived (18 to 180 minutes) , and are characterized by very severe unilateral head pain localized in or around the eye. Attacks may occur daily for some weeks followed by a period of complete remission. (CH is cyclic.)

Patients with CH, unlike those with migraine, are restless and prefer to pace about or sit and rock back and forth. Some will isolate themselves or leave the house to get into cold air. Some become aggressive.

Unilateral autonomic symptoms ipsilateral to the pain occur only during attacks: ptosis and pupil constriction (a partial Horner’s syndrome); as well as lacrimation, conjunctival injection, rhinorrhea, and nasal congestion. This indicates parasympathetic hyperactivity, and sympathetic impairment. Sweating and blood flow to the skin increase on the painful side.

The author presents a long list of suggested drugs for treatment and prevention. (The rather large number of choices suggests that none is “best” and individual trials are necessary. RTJ)

Primary care clinicians, if they practice long enough, will encounter a patient with CH. Recognition and treatment will provide most welcome relief, and may even be life-saving. (CH has been termed the “Suicide Headache” because the severe unremitting pain may drive some patients to take their own life.)

Therapy may be tried in primary care. Complicated cases require referral to a headache clinic.

Primary Prevention Is Much More Rewarding

9-10 MODELLING THE DECLINE IN CORONARY HEART DISEASE DEATHS IN ENGLAND AND WALES 1981-2000: Comparing Contributions From Primary Prevention And Secondary Prevention

Since the 1980s, coronary heart disease (CHD) mortality rates have halved. Studies consistently suggest that 50% to 75% of the decrease in cardiac deaths can be attributed to population-wide improvements in the major risk factors, particularly smoking, cholesterol, and high blood pressure. Modern cardiological treatments for CHD generally explain the remaining 25% to 50% of the fall in mortality.

Fall in mortality from CHD attributable to changes in risk factors:

Deaths prevented or postponed yearly (2000 vs 1981)

% changes* Primary prevention Secondary prevention Total

Smoking - 35% 24 000 5000 29 000

Cholesterol - 4.2 4700 3100 7900

Blood pressure -7.7 7200 500 7700

All 3 36 000 8700 45 000

(* % changes in the risk factor level in the population)

This article places our efforts to reduce risks (by enthusiastic prescription and by example) in concrete terms. This is a major public health achievement. Congratulations to all involved

If weight reduction and physical activity were also considered, benefits would be larger.

We never know, however, which individuals in our practices and in the general population are benefited.

This should not deter us.

I abstracted this article mainly to point out how important improvements in public health are. Certainly, primary care clinicians contributed a great deal.

Note the “Spin”

9-11 PREVENTION OF CARDIOVASCULAR EVENTS WITH AN ANTIHYPERTENSIVE REGIMEN OF AMLODIPINE, ADDING PERINDOPRIL AS REQUIRED, VERSUS ATENOLOL, ADDING BENDROFLUMETHIAZIDE AS REQUIRED.

This study asked—Would a regimen based on a calcium channel blocker (CCB) + an angiotensin converting enzyme inhibitor (ACE) lead to more favorable outcomes than a regimen based on a beta-blocker (BB) + a Thiazide diuretic?

The study was stopped prematurely after a median of 5.5 years (over 106 000 patient-years) because fewer patients in the CCB-ACE group had the primary endpoint. (Note: this did not reach statistical significance.)

Outcomes over 5.5 years ACE + CCB BB + Thiazide NNT*

(n = 9639) (n = 9618)

Primary endpoint 429 474 208**

Stroke (fatal & non-fatal) 327 422 65

Total cardiovascular

events & procedures 1362 1602 25

All-cause mortality 738 820 116

Incidence of diabetes 567 799 24***

(* NNT for 5.5 years to benefit one patient. ** Not statistically significant. The authors attributed this to under powering of the study. *** NNT to harm one patient (develop diabetes) (My calculations. RTJ)

“The findings of ASCOT-BPLA show that in hypertensive patients at moderaterisk of developing cardiovascular events, an antihypertensive drug regimen starting with amlodipine adding perindopril, as required, is better than one starting with atenolol adding a thiazide, as required, in terms of reducing the incidence of all types of cardiovascular events and all-cause mortality, and in terms of risk of subsequent new-onset diabetes.”

“Pending further information, we believe the combination of a beta-blocker and a diuretic should not be recommended in preference to the comparator regimen used in ASCOT-BPLA for routine use, but only for specific circumstances.”

This is an extraordinary (and expensive) study. I congratulate the investigators on their persistence. I feel they (and Pfizer) are disappointed with the outcome.

Benefits of antihypertension drug therapy would be much less when used for primary prevention.

But, there is an extraordinary degree of “spin” in this detailed 12-page article. As noted, the absolute differences between groups is small. And the NNT to benefit one patient over 5.5 years is large (25 to 208).

I believe these differences are of little clinical significance.

The number needed to treat unnecessarily for 5.5 years, with the amlodipine regimen as compared with the atenolol regimen, to achieve benefit for one patient is high, varying from 24 to 207.

I calculated the MNT (money needed to treat) for 5.5 years to benefit one patient. According to my pharmacy:

Cost per day $ Cost for 5.5 years $ Total $

Atenolol 50 mg 0.15 240

Hydrochlorothiazide 25 mg

(I could not access cost of

bendroflumethiazide) 0.09 180 481

Amlodipine (Norvasc 2.5 mg) 1.45 2910

Perindopril (Aceon 2 mg) 1.15 2308 5,218

Money needed to treat (MNT) with CCB + ACE vs BB + thiazide (at minimal doses) to prevent one adverse outcome over 5.5 years:

To treat 208 patients for 5.5 years to prevent one MI or one cardiovascular death::

CCB + ACE = 5218 X 208 = $1,085,344

BB + thiazide = 481 X 208 = $100,048

Difference = $ $985,296

To treat 25 patients for 5.5 years to prevent total cardiovascular events and procedures =

$130,450 and $ 12,025

Difference = $118,425

(My calculations RTJ)

Application of lifestyle interventions would be much more effective at no cost.

Study supported mainly by Pfizer.

See the following abstract for additional analysis.

More “Spin”

9-12 ROLE OF BLOOD PRESSURE AND OTHER VARIABLES IN THE DIFFERENTIAL CARDIOVASCULAR EVENT RATES NOTED IN THE ANGLO SCANDINAVIAN CARDIAC OUTCOMES TRIAL-BLOOD PRESSURE LOWERING ARM (ASCOT-BPLA)

(This article, by the same investigators, expands on the previous trial)

Differences between the groups included BP, HDL-cholesterol, triglycerides, potassium, fasting glucose, heart rate, and body mass index. All of these variables were significantly associated with rates of coronary events and stroke during the trial. (CCB-ACE, in addition to a slightly greater reduction in BP, was associated with reductions in other risk factors.) The investigators offer no explanation except . . .”That it remains possible that differential effects of the two treatment regimens on other variables also contributed to the different rates noted”.

These factors influenced outcomes favoring the CCB-ACE group. After adjusting for these factors the investigators determined that they accounted for about half the reported difference in coronary events and about 40% of the differences in stroke noted between the two groups. (Ie, the reported benefits in the CCB-ACE group were attenuated because, overall, the differences in risk factors favored this group.)

Note—the “spin” continues. If there is any benefit of CCB - ACE over BB-Thiazide, it is certainly minimal. This additional analysis markedly increases the number of patients needed-to-treat to more clinically insignificant levels. It also greatly increases the NNT(unnecessarily) and the “Money Needed to Treat” to benefit one patient.

It does not convince me to change first-line therapy away from BB- Thiazide. I would begin with a diuretic.

The Difference Between Relative Risk Reduction And Absolute Risk Reduction

9-13 EVIDENCE THAT NEW ANTIHYPERTENSIVES ARE SUPERIOR TO OLDER DRUGS

(This editorial comments, in generally favorable terms, on the preceding articles.)

“The amlodipine-based regimen in ASCOT . . . reduced major cardiovascular endpoints by 16%, stroke by 23%, and cardiovascular and total mortality by 24% and 11% respectively, compared with the beta-blocker atenolol, with or without bendroflumethiazide.”

“On balance, the ASCOT results endorse the European guidelines for the treatment of hypertension, which leave the choice of drug class for antihypertensive treatment to the doctor.”

Note again how misleading relative risk reductions can be. In absolute terms, the percentage reductions are by my calculation:

Relative risk reduction (%) Absolute risk reduction (%)

Major C-V endpoints 16 0.5

Stroke 23 1.0

Cardiovascular mortality 24 0.5

Total mortality 11 0.9

Absolute risk would be further reduced if the adjustments cited in the second study were considered.

Journal editors and investigators should not present relative risk reductions in their studies.

Equivalent Efficacy For Treating Early and Latent Syphilis, but Resistance May Occur

9-14 SINGLE-DOSE AZITHROMYCIN VERSUS PENICILLIN G BENZATHINE FOR THE TREATMENT OF EARLY SYPHILIS

A single intramuscular dose of 2.4 million units of penicillin G benzathine (Bicillin LA) is the recommended therapy for early syphilis. It is low cost. Adherence is no problem. Disadvantages include pain, the relatively high prevalence of self-reported penicillin allergy, and the need for injection equipment and trained personnel. In addition, there is some risk of transmission of blood-borne infections if the injection equipment is reused.

Azithromycin (Zithromax), a macrolide antibiotic with a long half-life (68 hours), would overcome some of these disadvantages. Efficacy against Chlamydia trachomatis, Neisseria gonorrhoeae, and Haemophilus ducreyi has been established. (Penicillin is not indicated and is ineffective against these organisms.)

Azithromycin is a promising candidate for treatment of primary and latent syphilis. [Latent syphilis is defined by 1) a positive serological test, 2) a normal CSF, and 3) no clinical manifestations.]

This study compared effectiveness of oral azithromycin vs intramuscular penicillin G benzathine in Tanzania. Cure rates at 9 months were 98% in the azithromycin group and 95% in the penicillin group.

There have been reports of azithromycin-resistant strains T pallidum in the USA and in Ireland. There was no evidence of resistance in Tanzania.

An accompanying editorial comments on two important reasons for caution: 1) The sustained success (50 years) of penicillin G benzathine. 2) The recent emergence of resistance to azithromycin.

Penicillin G benzathine is marketed as Bicillin LA. Bicillin LA is composed of one molecule of dibenzylethylene diamine + two molecules of penicillin G. Given intramuscularly, it maintains blood levels for 2 weeks or more.

It has been confused with Bicillin C-R, a combination of penicillin G benzathine and penicillin procaine G which produces blood levels more rapidly and of shorter duration. It is not indicated for treatment of syphilis.

Not too long ago, syphilis was considered a major stand-alone course in medical school. I remember well giving treatment with arsphenamine and neo-arsphenamine intravenously. The miracle of penicillin changed all that. The problem of syphilis remains, but is less a problem, at least in the USA.

Environmental Incivilities And Graffiti Have An Adverse Effect On Health

9-15 GRAFFITI, GREENERY, AND OBESITY

Independently of individual characteristics, the place of residence may be associated with health outcomes, including body size, and health-related behaviors such as the level of physical exercise. Perceived attractiveness of neighborhoods has been related to levels of physical activity. Incivilities, such as litter and graffiti, are associated with adverse effects on general wellbeing.

This study hypothesized that areas which are unpleasant, with many incivilities and few green areas, might discourage people from exercising, and thus influence the levels of obesity.

For individuals living in neighborhoods with high amounts of greenery, the likelihood of being more active was more than 3 times as high as that of those living in neighborhoods with low levels of greenery.

For respondents whose residential environment contained high levels of incivilities, the likelihood of being more physically active was about 50% less, and the likelihood of being overweight/obese was about 50% higher.

“In efforts to promote physical activity and reduce weight, attention should be paid to environmental facilitators and barriers as well as individual factors.”

What does this have to do about primary care? A great deal. Economically disadvantaged patients are also medically disadvantaged. Those who live in dangerous neighborhoods will, with good reason, not walk the recommended mile or two daily. And they do not have the means to go to a spa.

I recall an article I abstracted in December 2004 “Economics of Obesity” (Practical Pointers December 2004 [12-6]). This suggests that economics plays a large part in the obesity epidemic. Foods high in fat and sugar have become less expensive as obesity rates have risen. The poor are more likely to depend on these foods. The economic situation of low-income people forces them to adopt “obesogenic” diets. “If you live in the inner city you aren’t going to suddenly start eating mangos and playing tennis.”

These articles should make us more understanding and compassionate, and less critical. “Non-adherence” and “non-compliance” are often not due to lack of motivation, but to poverty and lack of opportunity.

Of course, obesity also occurs more and more frequently in the affluent. Just observe the crowd in an upscale Mall.

The cause of obesity is multi-factorial. Down-graded neighborhoods and lack of economic advantages is an important factor.

Coming Soon? Maybe

9-16 INTEREST IN INHALED INSULIN GROWS

The lungs provide a large surface area for drug absorption. Inhaled insulin is absorbed more rapidly than regular insulin given subcutaneously. The time to peak concentration of most inhaled insulins is nearly superimposable with the rapid-acting insulin analogues.

Controlled trials compared Exubera (one brand of inhaled insulin) + oral agents with injected insulin + oral agents. After 2 years, Exubera provided continuing glycemic control. HbA1c decreased 1.8%, compared with a 1.5% decrease in the injected insulin group.

Is it safe? Some studies have reported no adverse pulmonary events; some have reported cough as the most common side effect. A slight decline in carbon-monoxide-diffusing capacity occurred. Hypoglycemia, headache and dizziness have been reported. Patients with asthma absorbed lower amounts of insulin.

Longer term studies (a decade or more) are required to evaluate pulmonary function and insulin-binding antibodies, as well as use in children and smokers.

ABSTRACTS SEPTEMBER 2005

9-1 “THE MEDICAL HUMANITIES”, For Lack Of A Better Term

The essayist presents this provocative essay in more eloquent language than I have indicated in the abstract. I chose a few points on which to comment. Read the original. I believe most primary care clinicians will disagree with many of his observations. RTJ

Recently, an international conference of scientists and artists entitled “The Medical Humanities” was held in London. All attendees, scientists and artists, were deeply concerned about the growing dehumanization of medical care, yet unsure about how it might be combated.

So, what are “The medical humanities” anyway?

The commentator (an established poet and essayist) finds it very difficult to define.

“Distancing” is the process whereby physicians remove themselves from the particulars of patients’ experiences of illness so that they may render accurate diagnosis and treatment. It imperils the work of doctoring, converting it from a sacred vocation, borne of a desire and duty to alleviate suffering, into a mere financially rewarded, technically challenging line of work.

Medicine, in losing sight of how the arts and humanities inform and elevate the work of healing, is following the footsteps of larger societal trends. The view of any kind of work as simply a means to the all-important paycheck is widespread nowadays. Many find themselves looking instinctively to the humanities as a source of renewal, reconnection , and meaning. Alas, “the medical humanities” may ultimately provide little help in relieving the predicament. It does not assert the goal of educating aspiring physicians to be more empathetic. It fails to stipulate just what in its far-reaching realm is truly relevant to the ill and their caregivers.

Only with omnipresent and immediately accessible humanities resources for ourselves and our trainees can we nourish in our profession “the art of medicine’ from which we have become so estranged.

Thus, many of us find ourselves looking instinctively to the humanities as a source of renewal, reconnection, and meaning.

JAMA September 9, 2005; 294: 1009-1011 “A Piece of My Mind”, Editorial by Rafael Campo, Boston, Mass.

9-2 “THE MEDICAL HUMANITIES”: Attempting A Definition

I tried, along with the editorialist, to more clearly define “The Medical Humanities”, or more specifically “Humanities” It became confusing. Consider these definitions supplied by my dictionary:

HUMAN

Noun: A bipedal animal of the family Hominidae, species Homo sapiens.

A human being.

Man, broadly, as distinguished from a divine entity and from lower animals. [My dictionary is dated.]

HUMANITY

Noun: The state of being human

HUMANE; HUMANENESS

Adjective: 1) Marked by compassion, sympathy, or consideration for humans and animals.

2) Having the good qualities of human beings—kindness, mercy, compassion.

Noun: Used as a noun “The Humane” encompasses all the above qualities.

HUMANITIES

Noun: The branches of learning (philosophy, arts, language) that investigate human constructs and concerns as opposite to natural processes and social relations.

Those branches of knowledge concerned with man and his culture, as philosophy, literature, and fine arts.

The study of classical languages and literature—Latin and Greek.

If to be “human” is to have all the attributes of being “man”, logically this would include both:

1) The benevolent attributes (compassion, sympathy, caring, kindness, mercy, and consideration for others) and,

2) The malevolent attributes (brutality, oppression, hubris, domination, injustice, racism, sexism, elitism, violence, war, genocide, arrogance, greed, and 100 other evils.)

It seems to me that over human history 2) has outweighed 1).

Thus, it seems contradictory to morph “human” (good and evil) into humane. Ironically, adding the

“e” eliminates 2) and focuses only on 1) What a switch!

The question remains - What are “The Medical Humanities”?

The goal of the discipline is to help individuals attain the most complete maturity possible. A most important aspect of becoming a complete adult in our society is the ability to accurately comprehend the feelings of others and to act on them. This is not easily achieved. The “art of comprehending”, just as “the art of listening”, is a life-long quest. Very few individuals attain complete maturity..

How do we help ourselves and others attain complete maturity?

I agree with the editorialist that the ability and the desire to care for others are best instilled from an early age, by example and instruction at home. I also believe that an appreciation of “The Humanities” can and should be taught in college and graduate school. I applaud the change in emphasis of premedical training over the decades from the “sciences” to history, art, languages, and social studies. Perhaps “humaneness” can be taught in formal terms. But, that is only a part of the learning curve.

The editorialist asks—“What high-powered, busy professional—lawyer, banker, architect, or business executive—has the imaginative wherewithal, or even the inclination to integrate an appreciation of Bach or O’Keeffe amidst his or her daily tasks? Would this make anyone more “humane”? Does reading great literature add to one’s “humaneness”? The ability to address a patient in his own language certainly does help to “connect”.

Perhaps a study of “The Humanities” can help one achieve a higher degree of maturity. But I believe humaneness is best taught by example. A medical trainee would more likely remember and be guided by an example of caring demonstrated by a mentor than to remember the content of a course on bioethics. Achieving “humaneness” is a lifelong quest. Developing full “medical humanity” (the art of medicine) is a life-long quest. Just as is its counterpart, “the art of listening.”

So, to attempt a definition:

“A Humanity” is any product of human creativity and any human relationship which promotes understanding, kindness, good will, compassion, care, and caring.

“The Humanities” is the totality of all “A Humanity”.

“A Medical Humanity” (“The Medical Humanities”) does not differ from any other. However, medical professionals (nurses, therapists, dieticians, and physicians) may have more opportunity to express
”A Humanity” because they care for others when the others are most vulnerable.

Practical Pointers September 2005, Commentary by the Editor.

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“Doing It In The Doctor’s Waiting Room May Be Better Than Doing It At Home.”

9-3 SELF MONITORING OF HIGH BLOOD PRESSURE

Effective care of hypertension requires rigorous management with regular review and willingness to intensify drug treatment. The outcome of regular care depends on patients as much, or more than, it does on practitioners. Managing chronic diseases such as asthma and diabetes emphasizes the value of patients’ participation. The same is probably true for self monitoring of blood pressure.

Validated electronic measuring devices are now available to the public. Self monitoring satisfies the public’s demand for more self control and knowledge about health and disease.

This issue of BMJ reports a randomized trial¹ on self monitoring BP in the physician’s office The self measured and the professionally measured BPs were comparable. This suggests that hypertension guidelines are applicable to self monitoring.

The study reported a cost effective reduction in treatment of hypertension with no increase in anxiety.

Previous studies reported that home monitoring is more effective in controlling BP and achieving targets. This is probably explained by the absence of a white coat effect and better adherence to treatment.

Self monitoring of BP should be part of a plan to include patients in decisions about treatments. It allows active participation by patients without losing professional supervision. Office self monitoring may prove an advantage over self monitoring at home.

BMJ September 5, 2005; 331: 466-67 Editorial, first author J Carel Bakx, Radboud University, Nijmegen Medical Centre, Nijmegen, Netherlands.

1 “Targets and Self Monitoring in Hypertension” BMJ September 3, 2005; 331: 493-96 Original investigation first author R J McManus, University of Birmingham, UK.

Note that this study assessed patient self determination of BP in the doctor’s office, not at home.

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9-4 THE METABOLIC SYNDROME—A New Worldwide Definition

The metabolic syndrome (MS) (visceral obesity, dyslipidemia, hyperglycemia, and hypertension) has become a major public-health challenge world wide.

The association of several of these risk factors has been known for 80 years, but received scant attention until Reaven in 1988 described “Syndrome X”: insulin resistance, hypertension, low HDL-cholesterol, and raised VLDL-triglycerides. He omitted obesity (especially central obesity) which is now considered an essential component of the MS.

Several definitions have been proposed over the years.

Several of the factors are related to life-style.

The ultimate importance of the MS is that it identifies individuals at high risk for type 2 diabetes (DM2) and cardiovascular disease (CVD).

The conceptual framework used to underpin the MS (and hence drive definitions) has not been agreed upon. Opinions vary as to whether MS should be defined mainly to indicate insulin resistance, the metabolic consequences of obesity, or simply a collection of statistically related factors. The prevalence of the syndrome has been similar in any given population regardless of which definition is used, but different individuals are identified.

Another difficulty has been the applicability of the MS to different ethnic groups.

The International Diabetes Federation (2004) felt there was a strong need for one practical definition that would be useful in any country for the identification of high risk of DM2 and CVD:

1) Central (abdominal) obesity is a prerequisite to the diagnosis of the MS.

Waist circumference 94 cm or more for white men of European origin; 80 cm or more for women. (The cut points for other ethnic groups have been changed (See text) In the USA, cut points of 100 cm and 88 cm are likely to be retained in the definition.

Waist circumference is highly related to insulin sensitivity.

If body mass index is over 30, central obesity can be assumed, and waist circumference does not need to be measured.

Central obesity is related to each of the other components of the MS. If it is not present, the MS is not diagnosed.

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Plus any two of the following four factors:

2) Triglycerides 150 mg/dL and above.

3) HDL-cholesterol under 40 mg/dL in man and under 50 mg in women.

Both 2) and 3) are commonly observed in patients with DM2 and insulin resistance.

Both are risk factors for CVD.

4) BP 130 systolic and above; diastolic 85 and above, or previously treated hypertension.

5) Fasting blood glucose 100 and above, or previously diagnosed diabetes.

If above 100, a glucose tolerance test is strongly recommended.

Insulin resistance, which is difficult to measure, is not included.

Clinicians should use the new criteria for the identification of high-risk individuals.

Preventive measures are needed for those identified. Lifestyle modification with weight loss and increased physical activity will be beneficial. Drug therapy may be needed to address individual abnormalities if lifestyle therapy fails. There is no specific treatment.

Primary intervention

Moderate calorie restriction to achieve up to 10% loss of body weight in the first year.

Moderate increase in physical activity.

Change in dietary composition.

Clinical benefits are associated with small weight loss in terms of preventing (or at least delaying) conversion of persons with glucose intolerance to clinical DM2.

Secondary intervention:

In persons for whom lifestyle changes are not enough and who are considered at high risk for CVD, drug therapy for individual components of the MS may be required:

1) Dyslipidemia: Lower triglycerides; Raise HDL-c levels; Lower LDL-c levels

Fibrates improve all components of the dyslipidemia. They appear to reduce the risk of CVD in persons with the MS.

Statins reduce LDL-c. Several studies have confirmed the benefits of statins in the MS.

2) Elevated BP: C