Fall 2021
PMH STORY
The new PMH patient was well-known to the PMH doctor. He had cared for the patient’s wife for years, until she died from complications of chronic illness. The husband had not been ill, and with the death of his chronically ill wife, he decided to discontinue his PMH subscription.
Five years later, he called and asked if it would be possible to return to Dr. Kelly’s practice. He was not dissatisfied with his doctor, but he wanted to work with Dr. Kelly and felt like the PMH office would be better for him. We all knew this man. He had taken good care of his wife. We looked forward to seeing him again.
The staff greeted him as he came through the door. He was as happy to see us as we were to see him. Examination quickly showed that he had early dementia, confirmed in our subsequent workup.
So, our patient had been struggling with loss of his own confidence, his own ability to take care of himself, and, of course, the loss of his wife. Even at his first visit, he said to the doctor and the nurse how good it was to be back. We know how important understanding, familiarity, and responsibility are to all of us.
The PMH model emphasizes continuity of care. The PMH model also emphasizes comfort and convenience, our commitment to understanding our patients, their feelings, their needs and, of course, above all, the diagnosis, treatment, and prognosis of illness. PMH cannot provide everything a patient needs. There are consultants, hospitals, facilities and so much more. But for our patients, it starts with going to see the doctor, asking the doctor for help, and being respected and supported throughout their illness. We know that such support and care is found in offices and hospitals throughout our community. We are grateful to all of our colleagues for their care and understanding of their patients.
But for the gentleman who returned, now facing his own need, the PMH medical home gave him comfort, convenience, and the confidence that his needs would be met.
Allan R. Kelly, MD, FACP
PMH STORY
The patient was ill and had seen their urologist at intervals for months. A complication had arisen, and acute illness led the surgeon to send the patient to a hospital where Dr. Kelly relies on the hospital team for emergency care. There had been a prior diagnosis of prostate enlargement and several infections had occurred. Another infection was suspected, and he was admitted.
The next morning the patient’s daughter called Dr. Kelly. She was worried about lack of progress and that her father had had nothing to eat. Dr. Kelly was able to go to the hospital. He visited with the patient and family, examined the prostate and bladder, studied the information in electronic records, spoke with the nurses, and identified a probable obstruction caused by prostate cancer that required treatment. Arrangements were made for transfer to a different hospital where the patient’s urologic surgery team could address these issues immediately.
There is much in medicine today that seems administrative, perhaps even bureaucratic. It is hard to automate the complicated question of understanding a patient’s disease, understanding their needs, addressing their concerns, and, as the daughter put it, make progress. This is what PMH provided to the family. A call led to rapid assistance and cooperation with the rest of the team. But who does the family call? In PMH, everyone will know who to call.
Robert H. Kelly, MD FACP
MALARIA AND HUMAN VOLUNTEERS AT WALTER REED ARMY HOSPITAL
In the 19th century, research in the understanding of infectious diseases used human volunteers. The great pioneers of infectious disease, such as Louis Pasteur and Robert Koch, had their volunteers (often their own research assistants) exposed to microorganisms to prove that the microorganisms caused disease! Despite danger, people will still volunteer to undergo infection with microorganisms in order to learn more.
At Walter Reed Hospital, doctors recruited 25 volunteers in 2020. The research was to see if monoclonal antibodies administered before exposure could prevent infection with malaria parasites. The protocol called for infection of the participants with malaria by mosquitos. The forearm of the volunteers would be put in a closed space with infected mosquitos. Multiple bites would occur. 17 volunteers received monoclonal antibodies in various doses. 8 volunteers received no such monoclonal antibodies.
All of the 8 unprotected volunteers developed malaria parasitemia: they were infected. They were immediately treated. No serious illnesses developed. In the 17 volunteers who received the monoclonal antibodies, none developed malaria, even at the lowest dose of monoclonal antibody administered, and the antibodies were effective for up to nine months after infusion.
This experiment is a combination of the very old and the very new. What we do today is informed and guided by the giants in our past and the human experiments of today. Monoclonal antibodies play such a large role in our fight against the COVID virus. We see here that targeted monoclonal antibodies protect people from malaria. There are, of course, older ways to protect ourselves from malaria. Quinine and its derivatives, for example. But there will be situations where an intravenous antibody would be better. This is a breakthrough in what it says about monoclonal antibodies, and what it tells us about the hope for a malaria vaccine as well.
Allan R. Kelly, MD FACP
POSTMENOPAUSAL LASER TREATMENTS
Medical technology and procedures do not require the same approval process as drugs. For technology, safety is the key, and proof of efficacy is not required for technology licensing in the United States.
It can take a long time to complete a randomized control trial to help doctors determine whether the new technology is actually useful. In the meantime, the promise of the technology can go forward, and doctors who, based on testimonials, believe in the therapy, may recommend it to their patients.
Medical progress relies on randomized placebo control trials. So, it was good to see a publication from Australia in JAMA looking at fractional carbon dioxide laser therapies; (unfortunately branded as “Mona Lisa” treatments), versus sham treatments for postmenopausal vaginal symptoms.
The trial looked at multiple outcomes, including comfort, infections, and bleeding. Ninety women were randomized, half receiving the laser therapies, and half receiving a sham therapy, using the same equipment and the same experience, but delivering no laser treatment to the vaginal mucosa.
The article by Li, et al, concluded: “Among women with postmenopausal vaginal symptoms, treatment with fractional carbon dioxide laser versus sham treatment did not improve vaginal symptoms after 12 months.” There was no benefit of the laser treatment (compared with no laser) in any of the outcomes.
There was no meaningful improvement compared to a sham or pretended treatment. The average cost of laser treatments is $400 per visit. But with no definable benefit experimentally, laser is probably not a good choice. That a technology is available does not prove it is any good.
Allan R. Kelly, MD, FACP
PRP/PLASMA INJECTIONS FOR TENDONITIS
An experiment in England reported in 2021 randomized 240 patients with Achilles’ tendonitis into two groups. One group received platelet-rich plasma injection (PRP injection) and the other group placement of a dry needle without any injection (sham). Results of this PRP vs. sham were then analyzed.
Pain and function score was used to compare the two groups. Patients were followed up six months after treatment. Most patients improved regardless of the treatment. But pain scores were a little bit better in the sham group, though not statistically significant. Since a needle was used in both groups, there was no difference in complications between the two groups.
PRP, like stem cell treatments, is receiving a lot of attention. This study looking at Achilles tendinopathy did not show a benefit of PRP injection.
Use of topical treatments, simple oral analgesics, physical therapy, change in shoes, stretching, home exercise program, and time are effective and remain the best approach to the common care of musculoskeletal conditions. Plasma injections are apparently not worth the time, money, and trouble.
Robert H. Kelly, MD FACP
LIFE’S SIMPLE 7
Non-alcoholic fatty liver disease (NAFLD) is increasing and is the leading cause of cirrhosis. NAFLD is generally related to obesity. But the overlap of NAFLD and cardiovascular disease is notable. The most common cause of death in patents with NAFLD is cardiovascular disease.
The American Heart Association uses a new phrase “Life’s Simple 7.” It is probably Life’s oversimplified 7 but it does reflect the thinking of the American Heart Association, the Multi-Ethnic Study of Atherosclerosis group, and doctors generally. Here are the Healthy 7, all of which you will recognize:
- Healthy diet (less is more!)
- Regular physical activity, 75 to 115 minutes per week
- Normal body mass index, 23-27
- Not smoking (don’t smoke at all)
- Blood pressure, systolic <130
- Blood sugar, less than 125
- Total cholesterol, less than 200
There was a correlation between these healthy habits and the frequency of non- alcoholic fatty liver disease and cardiovascular disease. The phrase “Life’s Simple 7” is worth remembering.
Robert H. Kelly, MD FACP
QUOTES
“Of everything I’ve learned in medical school thus far, my favorite realization has been that I love people.”
Rachel Felix, medical student, 2021
“I had the good fortune of reconnecting [with my patient in the hospital]. We started right where we left off and it felt incredible. It felt like I had come home.”
Ryan Chippendale, MD, 2021
“Increasingly, evidence indicates that the electronic health record is imposing an intolerable burden on clinicians and may be degrading, rather than elevating, clinical care.”
Edward Melnick, MD, 2020
“We have to ask ourselves whether medicine is to remain a humanitarian and respected profession or a new but depersonalized science in the service of prolonging life rather than diminishing human suffering”
Elisabeth Kubler-Ross, MD, 1969