Winter 2024
PMH STORY
The patient was over 95 years old and living in a nursing care center. A life-threatening infection developed. Breathing was difficult. She was treated at the facility and cared for skillfully by the staff. Dr. Kelly provided treatment for the infection, made appropriate medication changes, and monitoring. She recovered. Today was our first visit at her care center since her recovery.
It was early morning, but she awoke from sleep. With 2 reminders, she recognized it was Dr. Kelly visiting and she expressed her thanks for the visit. I spoke to her about her recent illness and recovery. She was thankful for her recovery, thankful for those who cared for her and thankful for her long life, children, and God’s grace. This was her character, to be aware of what is good in life and give thanks. We addressed her concerns and issues. I shook her hand to bid her goodbye. In response, she grasped mine with both of hers, saying, “I am so proud that you are my doctor.” This is the first time she had ever talked about being proud of anything. Her usual approach to life was one of humility and thanksgiving. She is a woman of clear thought and strong conviction though her health was Frail.
The role of a doctor in a frail, elderly person’s life is important, often a necessity, and hopefully a source of comfort. It was with humility that I received her good spirit, thankful for all life has granted her and all that she had done in her 90+ years. That was her spirit during the ten years I have been her physician. There are times when doctors may learn as much from patients as patients may learn from the doctor. And when we earn their endorsement, whatever word they choose, it is because we are serving them, and that is good.
Robert H. Kelly, MD FACP
A GOOD NIGHT’S SLEEP: DON’T DRINK ALCOHOL
Men with no sleep complaints and who were active and busy volunteered to sleep in a lab. They were asked to volunteer for two nights. Half of the men on the first night had no alcohol and on the second night received an alcoholic beverage before sleep. The other half of the men reversed: Taking alcohol in the first night. No alcohol in the second night. The researchers looked at sleep events with and without alcohol. Sleep events (apnea, hypopnea, and hypoxia), interfere with the quality of sleep. Sleep events chronically may cause illness.
The number of sleep events on nights with alcohol was twice as high as the nights without alcohol. Apnea events, where the individuals stopped breathing for a period of time, was five times more common after the alcohol than after the nonalcohol beverage. The severity of oxygen desaturation was significantly higher after the alcohol.
Even small amounts of alcohol periodically can have significant effects on health. That is why many organizations, like the American Cancer Society, now state: “It is best not to drink alcohol.” Certainly, if you want a good night’s sleep, do not drink alcohol before you go to bed. Sleep apnea and hypoxia are big issues in men’s health. It is surprising to me to learn that alcohol may play an important role in this common and serious medical problem. Most likely, women will have the same response. This research used men because sleep apnea is much more common in men.
Allan R. Kelly, MD FACP
EXERCISE: HOW MUCH TIME AND HOW MANY DAYS PER WEEK?
Researchers at Mass General Hospital in Boston published an observational study in JAMA this last month. They looked at activity characterized as vigorous, which would be similar to a brisk walk or leisurely jog, playing a sport like tennis, or working out in an exercise room. They looked at total amount of time and compared people who had more or less than 150 minutes of weekly exercise. They also compared outcomes in people who exercised only 2 days a week (weekend warriors) and those who exercised at least 5 days a week (regulars). 150 minutes a week is not so much. Just 21 minutes a day. It could be on an exercycle, a treadmill, or a walk around the block.
It turned out that the weekend warrior and the regulars got the same benefit. Specifically, people exercising more than 150 minutes a week compared to people exercising under 150 minutes per week, there was a 22% reduction in atrial fibrillation, a 27% reduction in the risk of a heart attack, a 40% reduction in the risk of a heart failure event, and a 20% reduction in the risk of a stroke. Similar results were seen with other exercise levels. For example, exercising more than 230 minutes per week gave the same results as exercising more than 150 minutes per Week.
Research confirms the value of exercise. For your well-being, you do not need to spend hours in the gym or running marathons. 20 or 30 minutes daily is more than enough. If you exercise two days a week, an hour a day is a good place to be. But this recent study once again indicates to get moving, it's good for you. Whether you are a regular or a weekend warrior, exercise reduces the risk of stroke and heart attack.
Allan R. Kelly, MD FACP
BRUSH YOUR TEETH
When you wake up in the morning, brush your teeth. We all are taught by our parents to brush our teeth. Certainly, the dentist gets after us. The bacteria in our mouth affects the overall ecology of the body and health. This may even have an effect on the risk of dementia. A study published in the December 18, 2023, issue of JAMA Internal Medicine looked at the association between daily toothbrushing and hospital-acquired pneumonia and death. The researchers looked at 15 randomized clinical trials of ICU patients. Most of the studies were done outside of the United States, and many were from China. We have known for some time that oral care has an effect on the sick and the elderly. The intervention was to brush the teeth two times a day in the experimental group, and no brushing of teeth in the routine care. After having worked in ICUs for decades, I have never seen a nurse brush a patient’s teeth. This is something new. The research showed that brushing the teeth two times a day shortened ICU length of stay by almost two days, and reduced mortality by 20%. Brushing the teeth more than twice a day in the ICU did not increase the value.
The accompanying editorial emphasizes the value of this report, Dr. Datta from Yale School of Medicine observes that there is, “compelling data that toothbrushing is an effective strategy.” So, here is something new for us to think about for our hospitalized patients: if they can’t brush their own teeth, perhaps we should brush for them.
Allan R. Kelly, MD FACP
HOW TO HELP PEOPLE WITH PAIN?
We are constantly trying to learn how best to help people with pain. Experimental trials continue to explore the role of different types of medication, therapies, and advice to help people get better control of pain. All of us want to help our brothers and sisters who are in pain.
There is increasing controversy about which medications are most helpful for pain. Back pain and neck pain are a common experience in life and can be disabling. Researchers in Europe published a report in Lancet, July 2023. They randomized over 300 patients with moderate-to-severe back and neck pain who presented to emergency rooms or clinics needing help with their pain. They were randomized to two groups. One group was given a placebo to take for their pain along with Tylenol or Advil or whatever else came to hand. The other group got the same advice for over-the-counter medications as well as oxycodone, a narcotic, at a medium dose of up to 20 mg daily. Pain was re-evaluated at six weeks. The average pain score was higher in the patients given oxycodone than in the patients given placebo. Adverse events were also higher in the group given oxycodone compared to the group given placebo. In other words, in patients who had pain severe enough to take them to the doctor’s office or the emergency room, giving oxycodone only made their pain worse and gave them more complications than giving them the same advice and a placebo.
Oxycodone in this human experiment was of no value in helping people with neck and back pain. Narcotics can help people have peace and comfort when they are suffering, distressed, or facing something bigger than they can handle. Morphine has been used for centuries. I believe that we know better today than we did just 10 years ago about how to use these drugs. The bottom line is that we are learning that we have used narcotics too much, too frequently, and with no discernible benefit to our patients who have neck and back pain. Research like this published in the Lancet will guide our care in the future.
The research is also a reminder how human experimentation can put our current practice in a different light. The doctors and the patients, the nurses, and the institutions that support human research help all of us to do better.
Allan R. Kelly, MD FACP
HEALTH EFFECTS OF CHILI PEPPERS
We remember the admonition – you are what you eat! When I was about 8 years old, that was confusing. It makes more sense today.
Peppers (e.g., relleno, chili) are common in many cultures. Are they good for you? The active ingredient of chili pepper, capsaicin, may carry some risk of adverse effects, including coronary spasm. What we humans do by cultural habit may at times be for our own good and at other times risky!
A recent observation study reported on chili pepper use and health outcomes. About one-quarter of the study participants reported taking chili pepper spiced foods at least four times per week, and they were compared to people reporting no or rare use of such pepper. There were confounding variables, including the observation that the chili pepper group more likely adhere to the principles of a Mediterranean diet and better diet quality (less processed meat). On the other hand, the chili pepper group tended to have higher blood sugars, blood pressure, and weight.
Mortality hazard was 23% lower in the high use chili pepper group compared to no or rare users. Reduction in stroke and cardiovascular mortality was 30-60%. There is no proof that this risk reduction was caused by chili pepper use. This is an observational study and does not at all prove chili peppers prolong life, but it is an interesting correlation. I wonder if it proves that healthier people prefer a spicier or more varied diet. Chili peppers fit into the basic laws of good nutrition: balance, variety, moderation, and they taste great.
Robert H. Kelly, MD FACP
MEDITERRANEAN DIET
The Mediterranean diet is a diet low in red meat, high in fresh fruits, vegetables, whole grains, nuts, olive oil, and tomatoes. 16 studies published from 2006 to 2021 were studied. Adherence to the Mediterranean diet was monitored. 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 it is the diet patterns around the Mediterranean Sea and prudently restricting diet.
Another review of 30 controlled studies of sweeteners and sugar in the diet looked at cardiovascular mortality, diabetes, coronary events and death, heart failure, and stroke. In all of the studies published, there was a correlation between sweetener/sugar use with increased risk (10 – 20%). Health is affected by diet. Restrict sugars, enjoy fresh food in your diet!
Robert H. Kelly, MD FACP
QUOTES
“Novel procedures in medical practice find application so promptly in these days, that the scientific progress that they represent is all too often soon forgotten…[yet] The newest acquisitions to the healing art may sometimes become potential menaces until their limitations have been made clear.”
Editors, Journal of the American Medical Association, 1923
“I let that memory serve and inspire me to think of innovative approaches that will help make the distance and barriers between patients and clinicians smaller. I do not always succeed, but I try, I try to do something magical.”
Iyesatta Emeli, M.D., 2023
All too often, even the reputed scientist is found supporting a doctrine that is dangerously near uncertainty of demonstration, on the basis of inadequate investigation…the time has come when those interested in the dignity of science should protest, whenever it seems desirable, against any resemblance of finality or any assumption of authority in unwarranted statements of those who trade on scientific investigations.
JAMA Editors, July 21, 1923
“Every effort should be made not only to inculcate ethical ideals but to impress on a medical student the fact that success in medicine does not depend alone on exact diagnosis and successful treatment, and that in practice, you will have to treat patients, not cases.”
The Editors, Journal of the American Medical Association, 1908
“Misaligned quality measures can stifle clinical judgment and risk reducing the practice of medicine to mindless box checking. Over time, the number of quality measures has swelled to 2500, evolving into a confusing, time consuming and even soul crushing responsibility for the physician.”
Padmaja Patel, MD, 2023