Winter 2023

PMH STORY

A patient’s lab tests showed blood in the urine. Because of risk factors (including cigarette smoking and some toxic exposures) there was concern for cancer. Initial testing of the urine showed possible cancer. Referral was made to urology and the patient was scheduled for a consultation approximately 30 days later.

Two weeks before the consultation, the patient found himself on the road to go to an appointment in the morning and he was not quite sure where the appointment was. He called his PMH office. Review of his chart showed no known appointment set for that day. We called two offices where he visited, but neither showed an appointment scheduled for him that day. We called the urology office, but early in the morning they did not answer the phone and the answering service could not answer our question. Dr. Kelly recommended that the patient go to the urology office in case that is where the appointment was set.

An hour later, Dr. Kelly got a call from the urology office secretary. The receptionist said, “His appointment is for the end of the month, about two weeks away.” Dr. Kelly explained the situation, accepted the planned appointment, and thanked the receptionist for helping him. Dr. Kelly figured the patient would be asked to return for the previously scheduled visit.

Several hours later, Dr. Kelly received a copy of a consultation note done that same day from the urologist. With the patient there in the office, although his appointment was scheduled some weeks later, the urologist evidently saw the opportunity, discomfort, and need and basically said, “Let us get to work.” The urologist’s office did a good job. This is not so much a PMH story as it is a story of good care. It is good to be reminded of how things ought to be, and how things sometimes are. Our community can be one of the world’s best medical communities.

That was a good day for PMH.

Robert H. Kelly, MD FACP

FLU VACCINE REDUCES RISK OF DEATH

Flu vaccine saves lives.

We are accustomed to getting our flu vaccine. We are told it makes a difference, helps us to avoid hospitalization, and reduces the risk of wintertime death. Researchers in Sweden randomized 2571 volunteers who had survived recent heart attacks and were hospitalized. They were recruited through the study from 2016 to February 2020. The average age was 60, and 82% were male. None of the participants had had a flu vaccine for that year prior to the myocardial infarction. Half of the volunteers received a flu vaccine before hospital discharge. The other half got a placebo. During three years of follow-up, all cause death rate was 41% lower in the influenza vaccine group compared to the saline placebo group. The author of the study, Dr. Frobert, was quoted: “Patients with cardiovascular disease should get their annual flu shot…a flu shot could prevent cardiovascular death…”

There is general acknowledgement that flu shots are prudent. It is remarkable to see a placebo-controlled flu vaccine experiment study. The 41% reduction in death rates in persons with recent heart attack is surprising. Whether this result could be recreated in the United States, we don’t know. The experiment shows that an annual flu vaccine for our patients with vascular disease will likely save lives.

Allan R. Kelly, MD, FACP

LUNG CANCER SCREENING

The benefit of lung cancer screening is not as great as we would want. It leads to about a 20% reduction in lung cancer mortality. The United States Preventive Services Task Force has revised its recommendations for lung cancer screening. Prior recommendation applied to people 55 – 80 years with more than 30 “pack year” history of tobacco use. The new recommendation is people 50 – 80 years with a 20-pack year history. A third element includes persons who had  been smoking within the last 15 years. Persons 50 – 80 years old who have been smoking in the last 15 years or who have smoked on average more than one-half pack a day for 30 or 40 years (or one-pack a day for 20 years) should have an annual CT scan of the lungs.

Finding a nodule or suspicious area on a CT screening exam does not mean that there is lung cancer. A normal scan does not mean there will not be lung cancer. As many as 20% of scans will have an abnormality that is not cancer. Newer evaluation processes have reduced the problem of false positives. About 1:20 patients who have a nodule found at CT lung cancer screening will have lung cancer at an early stage. So, if there is an abnormality, remember there is about a 5% chance that the abnormality will be lung cancer. If a smoker has a normal scan, there is a 98% or better chance that they are free of lung cancer at that time. CT screen is not perfect, but it is a path to decreased death rate from lung cancer.

Robert H. Kelly, MD FACP

MORE ON PAIN RELIEF

Researchers at the Hennepin County Medical Center, Minneapolis did a double-randomized crossover trial. They subjected volunteers to pain from an ice-cold bath. The hand was placed in the ice bath for a period of 10 minutes and the severity of pain was indicated on a visual analog scale that was 100 mm across. The participants were asked to rank their pain at different times on that scale with their hand in the ice-cold Bath.

In the experiment, volunteers were exposed to multiple drugs: Tylenol alone, Tylenol plus hydrocodone (Vicodin), ibuprofen, and placebo.

With placebo, there was no change in pain compared to the pain experienced before administration of the blinded drugs. The pain relief with Tylenol was statistically significant and consistent, 10 mm on the visual analog scale. A reduction in pain from an average of 50 to an average of 40. Reduction with hydrocodone plus acetaminophen was the same, a reduction from 50 to 40. Interestingly, with the ibuprofen, there was no change in pain. and there was no placebo effect. In other words, pain experienced with ibuprofen and placebo tablets was the same as pain experienced without any premedication whatsoever.

All of us are familiar with popular pain pills that were marketed as acetaminophen with hydrocodone or acetaminophen with oxycodone, like Vicodin or Percocet. These drugs were marketed for years. But this research from Minnesota on healthy volunteers raises the question: Was the pain relief from these popular narcotic drugs achieved by the acetaminophen, with no significant added benefit from the narcotic? This research says it is so. Interestingly, the volunteers were asked about side effects. No side effects were experienced with Tylenol, ibuprofen, or placebo. But approximately half of the patients given the hydrocodone did experience side effects including nausea and Fatigue.

This was a small study but is indicative of research over the past several years that calls into question the value of narcotics for people with postoperative pain or acute pain.

Allan R. Kelly, MD FACP

REDUCE DEPRESSION AND ANXIETY: REDUCE SOCIAL MEDIA

Researchers in England report a randomized control trial looking at counseling patients on the use of social media. Volunteers recruited in Bath, England, were interviewed regarding their use of social media. The volunteers were then randomized, one group was counselled to stop using social media, specifically Facebook, Twitter, Instagram, and TikTok for one week and then to continue to use social media as usual. At the one- week follow-up, the group counseled to stop using social media for one week had a significant improvement in well-being, depression, and anxiety. The magnitude of benefit was correlated to the reduction of self-reported minutes on Twitter and TikTok, especially TikTok. The author’s comment: “The present study shows that asking people to stop using social media for one week leads to significant improvements in well-being, depression, and anxiety. Future research should extend this to clinical populations and examine effects over the long-term.”

Should I say, “stop using social media?” There is much left to learn, but it’s not a bad thought.

Allan R. Kelly, MD FACP

SYMPTOMS ARE COMMON

A study of Medicare beneficiaries over age 65 looked at how often symptoms occur. They found that in community-living population, only 1 of 4 had none of the common symptoms that were monitored: pain, fatigue, breathing difficulty, sleeping difficulty, depressed mood, and anxiety. Of the 75% of the community-dwelling older adults who had symptoms, nearly half had two or more symptoms and 14% had four or more symptoms. Symptoms are common and not always a sign of disease.

Pain and fatigue were the most common co-occurring symptoms reported by 32% of individuals. The most common triad of symptoms was pain, fatigue, and sleep difficulty in 13%. Decreasing independence in daily activities and mortality correlated with Symptoms.

We live with these common symptoms in our daily lives. It is when new symptoms arise and persist, or when old problems worsen, that we are more likely to ask a doctor for advice. But these common symptoms may not respond to treatment. Healthy people commonly experience irritating symptoms with no pathological cause.

Robert H. Kelly, MD FACP

QUOTES

100 years ago, the total per capital consumption of sugar in the United States was less than 9 pounds a year. It has increased by leaps and bounds, until now, this country is probably the largest consumer of sugar in the world… 

[Written in 1922. Since then, sugar consumption has continued to increase to more than 100 pounds per year.]

The editors, JAMA, 1922

The doctor as a private physician working for himself is more and more disappearing, but there will be general practitioners in out-of-the-way places as there are now; there will be men of rare talent and ability who will attract by their personality and who will remain individualistic in their work…

The editors, JAMA, 1897” [yes, 1897]

If a doctor has himself been the victim of a certain malady, forever afterward, is he more particularly interested in that affliction, and more sympathetic toward anyone so afflicted.

JMT Finney, MD, 1923

Our patients decide how to integrate our recommendations into their values and worldview, it then becomes our job to care for them with both empathy and humility, recognizing that we cannot really know what we would do if we were in their shoes.

Richard E. Laiter, MD, 2022

Physician independence has always meant more than an economic status. It has been the foundation of a professional ethos that imbues a dedication to science, a devotion to patient welfare, and a broad commitment to the health of the public. Critically, the medical and moral authority that physicians had rested largely on professional sovereignty.

Kevin A. Schulman, MD, 2022

It usually requires a considerable time to determine with certainty the virtue of a new method of treatment and usually still longer to ascertain the harmful effects.

Alfred Blalock, MD, 1899-1964