Spring 2023
PMH STORY
A patient with substance use problems developed serious complications. He was ill in a hospital out of state, cared for by medical school faculty. It was a difficult four-week hospitalization. Heart disease was identified, treatment was given, and he returned to Texas.
Dr. Kelly reviewed the medical center records. There was a need for local cardiology follow-up, which was arranged to be done the day after the patient’s next visit with Dr. Kelly.
The patient visited Dr. Kelly. And he explained that further consultation was possible. Dr. Kelly said that the specialists involved with his care were members of a large university group. The cardiologist group in town was also a big group. With the referral, Dr. Kelly assured the patient that both the university group and the Fort Worth group were excellent and sophisticated. Dr. Kelly said, “As you know, I am not a member of a group.” Without hesitation, the patient said, “Dr. Kelly, you don't need a group.” PMH does not substitute for a University Medical Center. PMH does not substitute for a group of skilled cardiologists. What PMH does is provide ready and convenient access to an expert physician who knows the patient’s case, who understands the patient’s care, and who collaborates with other physicians to meet the patient’s needs. And sometimes what the patient needs is the one physician. Having a Premium Medical Home can help achieve important goals.
Robert H. Kelly, MD FACP
AT HOME TESTING
We have learned from the COVID epidemic that at home testing helps people and doctors. We know how important at home testing for pregnancy has been, helping women make better decisions and understand what is happening with their bodies. At- home testing for COVID has also helped people to understand why they have a fever or why they do not feel good. You do not always need a doctor to understand why you do not feel good or to understand what is happening with your health or your life.
The FDA has now authorized, for the first time, an over-the-counter home diagnostic test to detect Influenza A, Influenza B, and COVID. Based on our experience for the past three years, this is a good move. It is good to make testing available to individuals who have knowledge, capacity, and motivation to do their own testing. Once they get their test result, then they can make a decision how they want to proceed. Many adults will not want to do their own testing, but they have that choice. When it comes to potentially treatable diseases like influenza, home testing will help people make good decisions.
Allan R. Kelly, MD FACP
HUMAN STOOL AS A SOURCE OF MEDICAL TREATMENT
The development of antibiotics has helped people in many ways and prevented many deaths. But the use of antibiotics occasionally causes distortions in the normal human microbacterial ecosystem. At times, these adverse effects of antibiotics in the colon ecosystem lead to opportunistic and potentially deadly infection of the gut, an infection called Clostridium difficile colitis. C. difficile infection can also lead to colon removal to save the patient’s life.
This clostridium infection, a complication of antibiotic therapy, has traditionally been treated with other antibiotics. In other words, a problem created by antibiotics is treated with antibiotics. Unfortunately, relapse is common.
Approximately 10 years ago, a series of experiments showed that this type of infection can also be treated simply with stool. The details are complex, but essentially a healthy family member can donate their own stool to a person sick with clostridium disease. These stool infusions, or “transplants,” are accomplished with colonoscopy. Stool treatment saves lives and prevents relapses.
Further analysis of what was in the stool that saved the lives of the sick has led to development of bacterial capsules to prevent relapses and cure the infection. Capsules containing multiple strains of benign Clostridium species are taken once a day for 14 days orally. Compared to placebo capsules, the use of these Clostridium capsules reduces the risk of infection by 75%. The study was published in JAMA 2023 by researchers from Canada and United States.
Living microorganisms can be used to help fight infections caused by other microorganisms. This breakthrough represents an important new frontier.
Allan R. Kelly, MD FACP
LYMPHOMA, CHEMOTHERAPY, AND HEART FAILURE: STATINS HELP
We have known for decades that the use of statin drugs, like rosuvastatin or atorvastatin, saves lives in people with coronary artery disease or who are at increased risk for a myocardial infarction. But how about people who do not have coronary artery disease, and who are at average risk of cardiac events? The research presented at the American Heart Association meeting included a randomized controlled trial of 300 patients with lymphoma. Lymphoma chemotherapy causes heart failure in a significant percentage of patients. But lymphoma is a fatal illness. Cure of lymphoma can open up decades of life that would otherwise be lost. How can we reduce the risk of heart failure in our lymphoma patients treated with certain chemotherapies?
Researchers asked: If statins prevent heart disease and heart deaths in high-risk populations, how about patients exposed to high-risk chemotherapy? The problem with chemotherapy is heart failure, not heart attack. In the experiment using volunteers with lymphoma on certain chemotherapies, one group was randomized to receive a statin, in the other group a placebo. The researchers studied cardiac ejection fraction as a measure of the strength of the heart. In the group treated with placebo, 22% had a significant reduction in the strength of their heart. In the group treated with statin, only 9% experienced a reduction in strength of heart function.
This research extends our confidence that statins can help protect the heart. We have gone beyond coronary artery disease (heart attacks), and now add chemotherapy side effects: threats to the strength of the myocardium. Statins have been on the market for 40 years. They are inexpensive, and widely available. They protect the heart. It is remarkable how we learn new things about old products that can save lives.
Allan R. Kelly, MD FACP
DECREASING ROLE FOR OPIATES
A study in Australia asked if morphine could reduce breathlessness in persons with moderately severe COPD. In the 20 th century, morphine (and opiates) became a go to solution for persons suffering symptoms of chronic disease. A person acutely short of breath, as with heart attack or heart failure, is quickly comforted by IV morphine. The theory was that morphine would relieve breathlessness and improve quality of life in patients with chronic breathlessness caused by COPD/emphysema. This was not widely used because of restrictions on opiate use, but it was a theory. The Australian study tested this.
The study compared people in the community who became short of breath while dressing or after walking 100 yards on a level field. They were not using continuous Oxygen.
Doses of 8 mg – 32 mg of morphine (extended-release preparation, or ER) were compared to placebo. The morphine dose was started at 8 mg and 16 mg and increased in two steps to a total dose of 8 mg, 16 mg, and 32 mg ER morphine daily.
Comparing those treated with morphine to those on placebo, there was no difference in how many steps were taken in an average day or in complaints of breathlessness. However, there was a difference found in hospitalization and death. In the morphine group approximately 33% of persons died or required hospitalization, whereas in the placebo group 18% died or were hospitalized.
Morphine has a role to play in acute suffering, at the end of life, and to treat postoperative pain. But the role of morphine and opiates in long-term pain control, breathlessness, and other symptoms of chronic disease is problematic. Except at the end of life or after trauma, opiates are generally not beneficial.
Robert H Kelly, MD FACP
THE MEDITERRANEAN DIET AND SUGAR
The Mediterranean diet is a diet low in red meat but high in fresh fruits, vegetables, whole grains, nuts, olive oil, and tomatoes. Sixteen studies published from 2006 to 2021 were reviewed, mainly conducted in the United States and Europe. Adherence to the Mediterranean diet was monitored by reported diet. Stroke and heart disease were lower in the group that adhered to the dietary guidelines. This observational study may prove that people who are good at sticking to a program do better than people who cannot, especially if the program resembles the diet patterns around the Mediterranean Sea and prudently restricting diet.
Another review of thirty controlled studies of sweeteners and sugar in the diet looked at cardiovascular mortality, diabetes, coronary events, death, heart failure, and stroke. In all of the studies published, there was a correlation with an increased risk of 10% to 20%. Our grandmothers might have said, you are what you eat. Health is affected by diet. Restrict sugars and enjoy fresh food in your diet!
Robert H. Kelly, MD FACP
STATINS AND BRAIN DISEASE
Researchers studied 3,000 adults free of dementia and Parkinson’s Disease (PD). During six years of follow-up, 50% of the adults in this British study (of elderly at risk of brain disease) went on to develop PD. After controlling for risk factors and other diseases, statin treatment was shown to reduce the risk of Parkinson Disease by 16%, even more so with the high intensity statins like Atorvastatin and Rosuvastatin. Postmortem examination of brain tissue looked at cerebral atherosclerosis. Statin treated brains had a 37% reduction in burden for atherosclerotic changes. The researchers concluded that statins reduced the risk of Parkinson’s Disease and vascular disease in otherwise healthy older adults.
Robert H. Kelly, MD FACP
QUOTES
The physician who makes all possible use of his daily clinical opportunities learns something new and useful every remaining day of his professional life. The daily clinical observations fortified by selective reading and standard textbooks and good medical journals afford a method of self education of the greatest value.
Frank Billings, M.D., 1923
“I sometimes wish every physician could understand the loss of a child. I wish they could understand how I miss (my daughter) achingly how I miss her in my bones… I wish every physician could understand – without going through the unimaginable – that our success in this profession is not defined by achieving external validation metrics, but rather by our ability to care for and about our patients.”
Ethan L. Sanford, MD, 2023
“I did perhaps the most important thing possible as a physician; I listened.”
Ferdinand Venditti, MD, 2023
Regardless of what the future holds our analysis demonstrated that increased consumption of sugar, sweetened, and possibly artificially sweetened beverages is a detrimental factor on cardiovascular health.
Chaya Krittanawong, MD, 2022