Spring 2022

PMH STORY

The PMH patient had never married and had no children. She had one brother who lived in Virginia. There were nieces and nephews, but none in Texas.

Growing old, dementia set in. She was increasingly frail. Serious medical problems indicated short life expectancy. The patient was no longer able to make her own decisions, and her brother, working with a PMH physician, made arrangements for hospice care. The goal was to create a more peaceful environment and to reduce or avoid trips to the emergency room. Trips to the hospital are often disruptive and anxiety-provoking, especially for those with dementia.

Near Christmas, the PMH physician recognized that the woman had had a change for the worse. Pneumonia was diagnosed from a chest x-ray and laboratory. Pneumonia in a patient like this is high-risk, and so the doctor went to her bedside to evaluate what was needed.

At the bedside, the woman was profoundly weak and unlikely to live long. The doctor called the brother, gave a report, and explained the situation. The woman was still able to open her eyes and say hello, and even said to the physician, “You’re my doctor, aren’t you?” During the phone call, the doctor asked if the brother would like to see his sister and talk to her. He said yes, and we switched to Facetime. The doctor held the phone so that the woman could see her brother. There was recognition, and the brother spoke to her. We all three visited. It was clear that the sister was comfortable, though weak, and the brother had the comfort of seeing her. After meeting with hospice and the nursing home team, the PMH doctor was about to leave the facility when a group of students from TCU came in with holiday cards for the residents at the nursing home. The PMH doctor asked if they would like to give the cards away individually, and a young woman said yes. The doctor said, “Would one of you like to give a card to the patient I just visited?” The student handed the card to her and they greeted each other with smiles, hello, and Merry Christmas. The card and visit by the student clearly brought the patient pleasure.

PMH is about continuity of care and professionalism. These priorities are good for patients, families, doctors, and the community at large. PMH strives to create a practice where the doctor is not “too busy” and can take the time needed to help the patient.

Allan R. Kelly, MD, FACP

AMERICAN HEART ASSOCIATION: GOOD HEALTH HABITS

After several decades of improving cardiovascular disease mortality, progress has slowed. There may even be an upward trend in cardiovascular mortality (Rehm et al, JAMA, 2016). Medical treatment, fitness, nutrition, and nonuse of tobacco have been cornerstones of past and future success. The American Heart Association reviewed these cornerstones and made new recommendations in 2021. Compared to prior recommendations, the focus is on an overall heart-healthy diet and not specifying certain foods as good and others as bad. There is increased focus on heart-healthy diet early in life. Key doctor recommendations include:

1. Vegetables and fruits, not meat and potatoes, should be the high-volume elements of diet.
2. Plant-based food, fish and low-fat dairy products are beneficial.
3. Avoid ultra-processed food.
4. Minimize added sugars.
5. Use little or no salt when preparing food.
6. Extra virgin olive oil has health benefits.

A final recommendation from the AHA: “Patients should not start drinking alcohol if they have never consumed any. Patients who already drink alcohol should limit their intake. Alcohol intake at any level to improve cardiovascular health is not recommended.” The AHA joins the American Cancer society in emphasizing alcohol use as a risk factor for poor health.

The new guidelines recommend 20 minutes a day of exercise. This can take any form: walking, Pilates, floor exercises, stationary equipment, and others. The key is to get up and move at least 20 minutes, seven days a week to improve strength and mobility.

Robert H. Kelly, MD, FACP

KNEE ARTHRITIS

Knee arthritis is common and can be disruptive, causing people to have to go to the emergency room or be admitted to the hospital. What is the best way to help people when the knees start to give out, and what are the goals of therapy?

A good experiment by doctors at Brooke Army Medical Center in 2019 enrolled 150 male and female patients with severe knee pain from osteoarthritis. 75 were randomized to physical therapy, and 75 to steroid injections in the knee. After one year, the patients were compared.

There was no baseline difference in the two groups of patients. The same sort of patients were randomized to physical therapy as to injections. The injection group was allowed to have a maximum of four injections in the course of the year. Most patients had two to three injections during that one-year period. After one year, the patients were compared.

The outcomes measured included pain relief, overall costs, and surgeries. The results showed better pain relief and better outcomes with physical therapy as compared to injections with steroids. Surgery on the knee occurred only in the steroid group. There were no surgeries in the physical therapy group. Most people want to do well with their knees and most people don’t want to have to have surgery. According to this research on knee arthritis, physical therapy is more likely to get people what they want than steroid injections.

Allan R. Kelly, MD, FACP

ONE OR MULTIPLE DRUGS FOR HYPERTENSION

Researchers in Australia compared low-dose multidrug therapy versus standard dose therapy for control of hypertension. One group was started on a compounded pill, called a poly-pill, with approximately one-quarter of the ordinary starting dose of Metoprolol (a beta blocker), Irbesartan (angiotensin receptor blocker drug), Indapamide (thiazide diuretic), and Amlodipine (calcium channel blocker). Low doses of each were compounded into a single capsule. In the other treatment group, patients were started on standard and escalating doses of a single medication with the addition of a second medication if the first medicine at higher doses was inadequate.

600 persons were enrolled. Some were already on blood pressure treatment with a single agent. None were at their desired goal blood pressure of less than 140/90. Blood pressure control was reassessed after 12 weeks and 12 months. Participants treated with the low-dose multidrug pill had significantly improved blood pressure control at 12 weeks compared with the volunteers treated more conventionally with higher doses of a single agent. Blood pressure control in the poly-pill group was also better at 12 months. Using a multi-drug low dose approach was more effective at achieving blood pressure control at 12 weeks and 12 months than was using higher doses of a single medication.

Robert H. Kelly, MD, FACP

PNEUMONIA: HOW LONG TO TREAT?

One of the great efforts of medical research is to define what is the preferred treatment. This question involves not only the selection of a drug or other treatment, but also the duration of treatment. The possibilities are vast.

We have previously written here about the duration of therapy for infection. We all remember the days of strep throat, where we were told to take all 10 days of penicillin, regardless of whether or not we were sick. Researchers in The Lancet 2021 looked at community-acquired (people living in their own homes who became ill) pneumonia requiring hospitalization. 310 patients, 18 years of age or older admitted to the hospital with pneumonia, were randomly assigned to two treatment groups. One group received three days of antibiotic therapy, followed by three days of placebo. The other group got six days of antibiotic therapy. Cure was defined as temperature of 100.4 or less, resolution or improvement in symptoms, and no additional antibiotic therapy for any cause, over 15 days of follow-up.

Seventy-seven percent of the patients in the three-day group and sixty-eight percent of patients in the six-day group were cured: cure was more common in the three-day group and less common in the six-day group. Adverse events were somewhat more common in the six-day group. This data supports reducing the duration of antibiotic exposure for patients treated in the hospital for community-acquired pneumonia.

One study is not enough to change the duration of therapy of important infectious disease problems like pneumonia, but we know now that shorter duration may work better than longer duration.

Allan R. Kelly, MD, FACP

STEPS PER DAY: FITNESS AND HEALTHY LIFE

In all settings, a program of physical activity (exercise), improves the quality of life and/or reduces adverse outcomes, including risk of death. A recent study looked at middle-aged adults and re-evaluated walking 7,000 steps per day.

The JAMA report found that men and women in the United States who walk or take at least 7,000 steps per day in middle adulthood showed a lower risk of mortality. 7,000 is not a magic number but it has been widely used. In this study, a pedometer monitored the number of steps taken. This was a study of healthy young adults.

Participants were divided into three groups, less than 7,000 steps, 7,000 to 10,000 steps, and more than 10,000 steps. Smoking history, body mass, alcohol use, healthy diet, and diabetes were all controlled. Approximately 2,000 subjects were studied with examinations and follow-up over the course of at least five years. 71% of patients were followed for 30 years!

Mortality risk was nearly 70% lower in the group with more than 7,000 steps compared to the group of less than 7,000. Higher number of steps (more than 10,000) was not better than 7,000. This is consistent with prior studies which have also shown the benefit of moderate exercise (more than 7,000 steps) compared to sedentary lifestyle (less than 7,000 steps).

If you are living a sedentary life and feel like you are not getting much exercise, get a pedometer and see just how many steps you are taking a day. They are available for less than $50. The pedometer empowers individuals to understand their own health. And if you find that you fall into the sedentary group and are taking less than 7,000 steps per day, then “steps” should be taken to avoid the low fitness category.

Robert H. Kelly, MD, FACP

QUOTES

“I greatly admired the style of my father’s death, putting aside the oxygen tent, and the similar decision of Uncle Will to die when it was time, without trying to eke out any extra days. When their deaths seemed to them inevitable, they simply died. Their acceptance was stamped with dignity, a quiet conscience, a sense of fitness.”

Charles Mayo, MD, 1968

“I knew, and know, that our system of not-care for the sick and scared is broken.”

Jessica Gregg, MD, 2022

“The glory of medicine is that it is constantly moving forward, that there is always more to Learn.”

William Mayo, MD, 1928