Articles Posted in Clinical guidelines

fatshame-300x230The medical establishment needs to take a hard, long look at its failing efforts to combat obesity and overweight, conditions that now affect just under 40 percent of American adults (93.3 million people) and 20 percent of youngsters (13.7 million) in the U.S.

That’s because doctors and medical scientists have “ignored mountains of evidence to wage a cruel and futile war on fat people, poisoning public perception and ruining millions of lives,” Michael Hobbes has reported in a long, strong story on the Huffington Post.

Hobbes has marshaled an array of available data to wag an unhappy finger at U.S. society, acting on conventional medical wisdom, for blaming and shaming those who are overweight or obese, contending that they lack self-control, discipline, and the personal fortitude to deal with what he says is clearly an uncontrolled medical and public health menace.

aspirinDoctors subject older patients to risky, costly, invasive, and painful tests and treatments, perhaps with good intention but also because they fail to see that the seniors in their care are individuals with specific situations with real needs that must be considered.

If  physicians too readily accept conventional wisdom in their field, for example, they may push patients 65 and older to take low-aspirin, with the popular but mistaken belief that this practice will help prevent heart attacks, strokes, and dementia. This doesn’t work, and, it increases the risk in seniors of “significant bleeding in the digestive tract, brain or other sites that required transfusions or admission to the hospital,” the New York Times reported.

The newspaper cited a trio of studies, published in the New England Journal of Medicine and based on “more than 19,000 people, including whites 70 and older, and blacks and Hispanics 65 and older. They took low-dose aspirin — 100 milligrams — or a placebo every day for a median of 4.7 years.”

docshistoric-300x234Doctors put their patients at grave risk by failing to stay current with professional best practices, eliminating outdated and ineffective therapies and approaches and instead learning and adapting better ways of care, notably treatments to help deal with the opioid crisis.

Vulnerable children can pay an unacceptable price, for example, for pediatricians’ unwillingness to “unlearn” what they were taught decades earlier in medical school, reported Aaron Carrol, a professor of pediatrics at Indiana University School of Medicine, a health researcher, and a contributor to the New York Times’ evidence-based column “The Upshot.” As he wrote:

In May, a systematic review in JAMA Pediatrics looked at the medical literature related to overuse in pediatric care published in 2016. The articles were ranked by the quality of methods; the magnitude of potential harm to patients from overuse; and the potential number of children that might be harmed. In 2016 alone, studies were published that showed that we still recommend that children consume commercial rehydration drinks (like Pedialyte), which cost more, when their drink of choice would do. We give antidepressants to children too often. We induce deliveries too early, instead of waiting for labor to kick in naturally, which is associated with developmental issues in children born that way. We get X-rays of ankles looking for injuries we almost never find. And although there’s almost no evidence that hydrolyzed formulas do anything to prevent allergic or autoimmune disease, they’re still recommended in many guidelines.

brca-cancer-risk-261x300Even as a pair of prominent researchers saw their reputations crumble over controversies connected to their work, a University of Washington team showed anew the importance of rigorous, transparent, independent, and widely shared medical science  to patients, in this case those with cancer.

Let’s start with the seemingly positive take that’s accompanying publication in the journal Nature of research regarding an open database with prospectively valuable information on BRCA1 variants, what some have dubbed the “cancer risk” gene.

Everybody carries both BRCA-1 and BRCA-2 genes, named because BR stands for breast and CA for cancer. All of us have two copies of each gene, one passed down from our mother, the other from our father. The genes make proteins that help repair errors in our DNA that pop up from time to time when our cells divide and duplicate their genetic code.  Mutations in either BRCA gene can disable the repair process and make both women and men carriers of the defect susceptible to certain kinds of cancer.

theater-228x300What’s an internist to do when an 81-year-old patient, already in failing health with advanced emphysema, seeks a second opinion because he’s been told his prostate specific antigen (PSA) levels are unacceptably high? This senior also has been advised to schedule a prostate biopsy urgently to determine if he has cancer. Can this discussion with both a scared patient — and his bright, concerned personal doctor — be any tougher?

For Andrew Lazris, who is also a geriatric specialist practicing in Maryland, this was a hard, complicated case because it involved his dying dad.

It also exemplified for him the work that he has undertaken with Eric Rifkin, an environmental scientist and adjunct researcher at Johns Hopkins University, in ensuring that patients retain their fundamental and critical right to have a say in their care. And, in doing so, they have developed what they argue is a clear, comprehensible way to help patients grasp and deal with the inevitable uncertainties, risks, and complexities of the array of medical treatments they can get overwhelmed with by doctors, hospitals, Big Pharma, medical device makers, and others in health care.

Bundle-300x151Federal regulators may be forced to reconsider their plans to curtail a cost-containing experiment that affects some of the most commonly performed surgeries — knee and hip replacement procedures that hundreds of thousands of seniors undergo annually through their Medicare coverage at a cost to taxpayers of billions of dollars.

Under the Affordable Care Act, doctors and hospitals were pushed to adopt a new and different way to think about and to bill for these surgeries, which, by the way, aren’t risk free. Instead of patients getting flooded with bills from each provider involved — the lab, radiologist, anesthesiologist, surgeon, hospital, and so forth — Obamacare got all the parties together and told them they would get a single, “bundled payment.” Hospitals, typically, then acted as the chief point of contact, getting the providers to figure their fair share, billing patients (once), and collecting reimbursements and distributing them appropriately.

The system seemed to work: costs declined, the quality of care went up, and patients expressed relief that their mailboxes weren’t jammed with a blizzard of the usual incomprehensible medical bills. But doctors, hospitals, and insurers kept grumbling. The Trump Administration and Republicans in Congress, as part of their relentless and counter-factual assault on the ACA (more on that in a second), took aim at bundled payments and talked about changing and eliminating this approach.

holick-214x300Media coverage of diet and nutrition topics, for their abundance of hype and sheer bunk, may take the cake. Some recent, solid reports not only offer examples of the scope and scale of this public tomfoolery and its costs but also the reasons why it persists.

Let’s start with reporter Liz Szabo’s deep, detailed take-down of Michael Holick, a Boston University endocrinologist and unabashed pusher of a widespread medical myth that many of us may be deficient of Vitamin D, the so-called sunshine supplement.

Szabo, investigating for the independent, nonpartisan Kaiser Health News Service and the New York Times, reported that Holick has advocated for Vitamin D sufficiency guidelines that created in 2017 alone a $936 million market for its supplementation, with Americans spending another $365 million for more than 10 million vitamin deficiency tests paid for by Medicare.

costhospitals-300x218Hip and knee replacements  have become some of the nation’s most commonly performed surgeries with hundreds of thousands of Americans, many of them older, having their knees or hips replaced with metal, plastic or ceramic each year. Uncle Sam’s Medicare program is paying around $7 billion annually for all this work. But here’s a nasty revelation about knee replacements, in particular: Hospitals don’t know how much they cost.

In case you ever doubted the profit-seeking motive in these institutions’ practices, the Wall Street Journal reported some eyebrow-raising information on hospital pricing and costs, based on a Wisconsin facility’s rigorous efficiency study of knee replacements.

The procedure had risen in price by 3 percent a year for almost a decade, hitting a $50,000 cost per such surgery by 2016, including coverage for the expense of surgeons and anesthesiologists.

hennepin-300x200Big Pharma howls often about the federal Food and Drug Administration path to get prescription drugs approved for markets, complaining current regulatory processes take too long and, with their requirement for rigorous clinical trials, are too tough.

Even as drug makers seem to be finding sympathetic officials to make these regimens faster and laxer, some voices want the FDA to consider costlier and what they say is more realistic and useful scrutiny of drugs that goes beyond current attempts  to find if they are safe and effective.

Shouldn’t regulators — at the FDA or elsewhere in the federal bureaucracy — help consumers much more to know the answers to “two crucial questions: How do … new therapies compare with already known ones? What are the relative benefits and harms in a particular situation, for a person like you?”

brainlinetbi-300x245Rigorous researchers avoid leaping to unfounded conclusions, but  it’s hard not to look at two separate studies on areas of high current interest and just go “Hmmm ….”

In the first work, experts from the federal Centers for Disease Control and Prevention analyzed available reports and surveys to find that 15.1 percent of American high school students or 2.5 million or so “reported having at least one of these concussions” in the most recent year, while 6 percent reported two or more concussions.

The researchers said:

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