Winter 2022

PMH STORY

COVID has caused changes, but the old lessons are still good. I recently visited a PMH member in long-term care. Because of covid, the doors were all locked. Knocking on the door for several minutes, calling the phone number, leaving a message, pressing the various buttons that were available to be pressed were all ineffective, and the door remained locked. Through the door window, I could see a few residents gathering in the dining room for supper. Everyone was busy. A man living at the facility could see I was at the front door and needed to get in. He came in his motorized wheelchair to the door. I noticed his hat: Korean and Vietnam vet. He unlocked the door, and I was able to enter, visit, and provide care to the PMH member that was at the facility.

On the way out, I stopped at the table where the man in the wheelchair was with two other men. I thanked him again for his help. We talked a little bit about football games. I told him that the important game that weekend was on Sunday: The Pee Wee Baseball Team Seawolves play the Yard Ducks. (I have a grandson on the Seawolves) Prior to parting, I thanked him for helping me. As I left the facility, I saw 15 newspapers piled up outside the front door. The door was about to close behind me (I did not want that to happen), so I quickly grabbed the door and, one armful at a time, I got all the papers moved indoors. The staff showed me where to leave them, and then I was on my way.

This time together with the other residents, who were not my patients, was possible because I was not too busy. I had time to pay attention and enjoy the fellowship. PMH changes my day for the better. 

Robert H. Kelly, MD, FACP

FLU VACCINE REDUCES RISK OF DEATH FOR HEART PATIENTS

We are accustomed to getting our flu vaccine, and we know the vaccine prevents illness and death even in healthy people. We have been told the flu shot makes a difference, helps us to avoid hospitalization, and reduces the risk of wintertime death. So, placebo- controlled trials of flu shots are difficult.

Researchers in Sweden randomized 2571 volunteers who were admitted to a hospital with heart attack.They were recruited 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. But a 41% reduction in death rates in persons with recent heart attack is surprising. Whether this result could be the same 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

COFFEE AND DEMENTIA

A study on coffee and green tea was done by internists and rehabilitation specialists and published in the Journal of the American Geriatric Society in 2021. Participants were 13,757 community dwelling individuals 40 to 74 years old. A questionnaire, completed between 2011 and 2013, measured consumption of coffee and green tea. The researchers asked whether coffee or tea consumption could influence the development of dementia.

The results: participants with higher coffee consumption had significantly lower risk of developing dementia. The total quantity of coffee consumption increased that level of protection. The authors report, “Coffee consumption of greater than three cups of coffee per day was associated with 50% reduction in dementia risk.” This was the first study I have seen looking at coffee and dementia. The association was more robust in men than in women. The risk of dementia in men drinking greater than three cups of coffee per day was cut by 80%.

Coffee is a complex biological preparation which includes not just caffeine, but many other phytochemicals. Observational studies do not prove cause and effect, simply association. Nevertheless, it is another sign and a reminder that not all habits are bad.

Allan R. Kelly, MD, FACP

OPIATE SAFETY: IS OLDER SAFER?

Humans have used opium for thousands of years. Opioids, unlike opiates, are manufactured molecules and do not naturally occur. Opium contains many opiates, and the most prominent are morphine and codeine, which make up approximately 80% of the opiates found in opium. Since the introduction of the opioid heroin early in the 20 th century, the opioids have competed with the opiates for relief of pain but there have been few, if any, head-to-head randomized control trials comparing opiates (morphine and codeine) with the opioids (such as heroin, oxycodone, hydrocodone, and tramadol). Researchers in Barcelona, Spain compared codeine and tramadol. Tramadol is a synthetic low potency opioid. Both codeine and tramadol are narcotics used for pain. This was an observational study, so it lacks the reliability of a placebo double-blinded controlled study.

The study looked at prescriptions for tramadol and codeine from 2007 to 2017. The researchers studied both death rates and adverse events in the two groups. Patients prescribed tramadol were twice as likely to die during the period of observation. Specifically, the death rate was 5.6 per 1000 years of use in the codeine group, but 13 deaths per 1000 patient years in the tramadol group. Other adverse events included fractures and cardiovascular events. These adverse events were higher in the tramadol group compared to the codeine group.

Another observational study has shown increase in mortality in patients with osteoarthritis given prescriptions for tramadol compared to patients treated with other drugs. So, we are being more cautious with tramadol and other narcotics. Increasingly there is data showing that the older opiates are safer than the newer opioids.

There are excellent alternatives to opiates for pain control. But there will be times in a person’s life when an opiate will be helpful, and a great relief to the patient and to the patient’s family. People have used opiates such as codeine and morphine for many thousands of years. In this research, codeine appears to be a better choice for safety and efficacy compared to tramadol, which was licensed in 1995.

Robert H. Kelly, MD, FACP and Allan R. Kelly, MD, FACP

IS THERE A BETTER TIME OF DAY TO TAKE BLOOD PRESSURE MEDICINE?

A randomized study of 19,000 patients in Spain looked at the timing of blood pressure medications. Half were told to take all blood pressure medicine in the morning. Half were told to take all the blood pressure medicine in the evening. At follow-up appointments, the advice was repeated. After 6 years, the researchers compared the risk of cardiac events or stroke in the two groups.

Adverse outcomes over the course of six years were 50% lower when taking blood pressure medicines at nighttime. The 6-year risk of a vascular event was 12% in the morning group and only 6% in the evening group. Blood pressure measurement in the nighttime group were 3 mmHg lower. However, a 3 mm reduction in blood pressure alone does not explain the 43% improvement in outcomes reported. But critics point out the trial design was potentially biased as prior studies have not established superiority of nocturnal dosing.

We await confirmatory studies to make a general recommendation. The Spanish researchers have challenged common medical practice, and we are paying attention.

Robert H. Kelly, MD, FACP

ANKLE ARTHRITIS: PRP

Ankle osteoarthritis is common, affecting 3% to 4% of adults. Dutch researchers compared platelet rich plasma (PRP) ankle injection to routine care in people with osteoarthritis. PRP is derived from a person’s own blood. The effect of the blood product when injected into the ankle was theorized to promote healing and pain relief. One hundred patients were randomly assigned either to a PRP injection or placebo injection. Average age was 56. The American Orthopedic Foot and Ankle Society Symptoms Score (AOFAS) was used, and a higher score means better function and less pain. PRP or placebo injections were given every 6 weeks for 2 injections. On the AOFAS, the PRP injection group improved from 63 to 73, whereas the placebo group improved from 64 to 75. PRP failed to improve ankle symptoms more than a placebo injection.

The benefits of PRP injections to date have not demonstrated benefits in controlled trials, but research continues.

Robert H. Kelly, MD, FACP

QUOTES

“The only one who knits my care together into a coherent whole is my 76-year-old primary care physician…we are more than a collection of our parts and need a new generation of doctors to see us as whole people and treat us that way.”

Richard Hencke, M.D., 2022

“Focusing on the patient: it is why we choose to become physicians…if I could spend my time with my patients and not all the hassles of documentation, billing, pre- authorizations and quality metrics, I would be a much happier physician!”

Linda Siy, M.D., 2018

“In the transition to electronic medical records, mandated through legal maneuvers and encouraged through financial incentives, clinical comprehension has been compromised.”

Mark Rosenberg, M.D., 2021

“We should all be so lucky to work at something we love until the day we die.”

May Owen, M.D., 1968

“The reward for work well done is the opportunity to do more.”

Jonas Salk, M.D., 1952