The Doctor Weighs In

by Pat Salber, MD

In the early days of the clinical practice guidelines movement, doctors used to complain that it was “cookbook medicine.” As a pretty good cook, who still uses cookbooks, I say, great – when you follow the directions of experts, instead of “winging it,” you increase the odds of getting a good outcome.

So it should be not a surprise that a new study, in the July 23 issue of Archives of Internal Medicine, found that outcomes of hospitalized heart-failure patients are improved when hospital personnel follow clinical guidelines.

OPTIMIZE-HF (“Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure”) is a heart failure guidelines/quality improvement program adopted by the American Heart Association (and sponsored by drug maker GlaxoSmithKline). The program provides hospitals with tools to help improve the reliability of care, including standardized admission orders, discharge checklists, pocket cards, medical chart stickers, best-practice algorithms and critical pathways. It is currently being used by 259 hospitals across the US.

The study, led by Gregg Fonarow, MD from UCLA’s Department of Medicine, looked at data entered into an online OPTIMIZE-HF performance improvement registry. Admission, hospital, discharge care, and outcomes (death and hospital readmission rates) data on 48,612 heart failure patients were entered into the registry between March 2003 and December 2004. A subgroup of 5,791 patients were followed for an additional 60-90 days after they were discharged from the hospital.

The researchers found statistically significant improvements in three of four of the Joint Commission on Accreditation of Healthcare Organization's performance measures used to gauge the quality of heart failure care in hospitals. They included:

· Better patient discharge instructions. The rate of giving complete medical instructions to patients increased from 46.8 percent at the beginning of the study to 66.5 percent by the study's end.

· Smoking cessation counseling. Hospitals provided smoking cessation counseling to 75.6 percent of the patients at the end of the study, compared with 48.2 percent in the beginning.

· Left ventricular function assessment. Evaluating the heart's left ventricle systolic function rose from 89.3 percent to 92.1 percent.

A fourth measure, the rate of angiotensin-converting enzyme inhibitors (ACEIs) prescribed to eligible patients at discharge was 75.8% at baseline. This rate did not improve during the 2-year study.

There was a statistically significant reduction in the mean length of stay for these patients, going from 7.5 days at baseline to 6.2 days at the end of the study. In addition, were trends for reduction of in-hospital mortality, postdischarge death, and combined postdischarge death and rehospitalization, but they did not reach statistical significance.

So patients did better and hospital days were reduced (and so were costs presumably). What’s not to like? According to the lead author, Dr. Fonarow, as quoted in the Washington Post:

"If similar improvements had occurred at hospitals nationwide, this would translate to 40,000 less deaths and 1.4 million costly hospital days eliminated per year. Despite compelling scientific evidence and national guidelines for use of key life-prolonging agents and lifestyle changes, gaps exist in heart failure treatment. We hope more hospitals will adopt this validated model for enhancing heart-failure patient care."

Amen.

Check out DiabetesPHD on the American Diabetes Association website. It is a risk assessment tool that uses Archimedes, a sophisticated computerized health modeling program to determine your risk of developing heart disease, stroke, and/or diabetes and its complications (kidney failure, eye problems, foot problems) over the next thirty years.

The best thing about this program is it gives you a chance to see what happens to your risk if you lose weight, reduce your blood pressure or improve your cholesterol levels. You can also model the impact of taking certain medications or having better health habits (not smoking, taking an aspirin a day if you are over 40). It is pretty cool to watch the graphs of your risk improve in front of your eyes when you lop off 40 pounds or lower your cholesterol by 40 points.

The advice DiabetesPHD provides is specific to you since you entered your numbers which were then run through the Archimedes model (which is based on published scientific studies of health risks). The advice contains hyperlinks so that you can easily access more information on topics relevant to your risk profile.

Here’s how it works. You go to the data entry page of the tool and type in relevant information about yourself, including the names of any medications you are taking for diabetes, high blood pressure, or abnormal lipids -- so be sure to have you medication list when you sit down to use the program. You will also be asked to enter your latest blood pressure, blood glucose, as well as total cholesterol, LDL and HDL levels. It can calculate risk without these numbers, but is more accurate if you can provide them. You are also asked to answer a series of yes/no questions about your health history.

Once all of the information is entered you are given the choice of getting your results now or receiving them by email. It can take a number of minutes for the program to calculate your results because your information is being run against a very complicated health modeling program. So put aside about 15 – 20 minutes to use the tool, including entering the data and waiting for the results.

It is well worth the effort. The combination of a clear visual display of your health risks now and over the next 30 years and being able to see the impact of improvements in risk factors is powerful. These pictures are definitely worth a thousand words.

Pat Salber, MD, MBA

Here is a small quiz: Which of the following drugs is the most addictive?

1. heroin

2. crack cocaine

3. oxycontin (of Rush Limbaugh fame)

4. opium

5. none of the above

If you selected any of the options 1-4, you are dead wrong. The most addictive drug is: nicotine.

How does nicotine addiction work?

In one of our previous posts, we dealt with the neurobiological basis of addiction. Deep inside the brain there is a structure, called the nucleus accumbens, that pretty much controls our sense of pleasure. Most of the neurons that make up this nucleus have dopamine receptors on their surface, but some have receptors that are called ‘nicotinic’ and it is to these receptors that nicotine binds. After a few encounters with the drug, the affected neuron sort of ‘dials down’ its response to the stimulus. But now the user is hooked; to maintain the same level of stimulation the cell will increase the number of receptors on the membrane, so as to bind more nicotine molecules. Again, the response to the stimulus abates and even more receptors are produced by the cell. This is the epitome of a vicious circle.

Now, we understand the neurobiological basis for addiction, but even the drug dealer, no neurobiologist he, knows enough to push free drugs on kids in hood. Once they are hooked, there is in reality no escape for them.

Enter the tobacco drug dealers. The story by now is well known and does not need repeating.

The cigarette is probably the most effective drug delivery device ever invented, and nicotine one of the most addictive drugs. People addicted to several drugs, including tobacco, would tell you that kicking the smoking habit is more difficult than kicking a cocaine or heroin habit. So after the public uproar, the punitive court settlements, the tobacco companies ‘coming clean’ and expressing heartfelt contrition, their cynical websites dispensing advice on how to quit smoking-after all this, we are treated to this shocker:

Nicotine content in American cigarettes is up By 11%

Yes, you read it right. A report by the Harvard School of Public Health  simply looked at the industry’s own annual reports to the Massachusetts Department of Public Health.

What did they find?

Upon analyzing the data, the scientists found that the manufacturers of cigarettes have increased the level of nicotine yield in cigarettes by an average of 1.6% each year between 1998 and 2005. And they did this in two ways:

§ First, by directly altering the concentration of nicotine, and

§ Secondly, by changing the design features to increase the delivery efficiency of nicotine.

This was a deliberate strategy to increase the nicotine concentration in the smoke, and do it slowly so as to escape notice. Indeed, it was successful-it took 7 years to detect.

Many questions--few answers.

· How could they be so brazen? I thought that only criminals could be so amoral when they kill in cold blood.

· Where was the scrutiny of the Public Health departments of the fifty states that received those data every year?

· How did it happen that such an addictive drug is still legal while all other ‘recreational drugs’ are illegal?

· How did it happen that the FDA would not approve drugs that are infinitely safer than tobacco, but allows an essentially unrestricted access to this recreational drug?

Tobacco co. CEOS testifying that tobacco is not addictiveThe answer to the last two questions is actually well known. The tobacco industry exerted tremendous pressure on many legislators, most of them paid handsomely by the industry, to prohibit the FDA from regulating tobacco products. In fact, FDA commissioner David Kessler, who had raised the issue, was ushered out shortly thereafter.

My last question, for which I don’t have an answer:

Where is the rage?

Goldstone, the famous British prime minister at the beginning of the 1900s, is reputed to have said that ‘people get the government they deserve’. How true, and how depressing. Where is the rage?

Dov Michaeli, MD, PhD

In my last posting, we discussed the adaptive response to lack of oxygen in wounds and in solid tumors. These are situations in which only a small area of the body is affected, while the oxygen supply to the rest of the body remains normal. There are situations, however, in which the whole body suffers from lack of adequate oxygen supply. The most common is emphysema , a chronic lung condition often related to cigarette smoking.

The structure of our airway

Our airway looks like a tree. The trunk, the main windpipe, is called the trachea. It branches into smaller caliber branches, or bronchi and those, in turn, give rise to progressively smaller branches called bronchioles. The last and smallest twig, the terminal bronchiole, opens into an air sack (alveolus) which looks like a tiny balloon. The alveolus is made up of a very thin wall enclosing an airspace. Thousands of these air sacks (alveoli) make up the lung.

When we inhale our chest expands, the lungs expand and air rushes into the alveoli. Oxygen is then taken up by the blood vessels (capillaries) that course through the walls of the alveoli and carbon dioxide is released from the blood into the alveolar airspace. When we exhale, the elastic alveolar walls contract, chest volume decreases, and carbon dioxide is expelled outside of our body. Think of a balloon letting out air through its elastic contraction.

What is emphysema?

To understand what happens to the emphysematous lung, think of a balloon that has seen better days before losing its elasticity. Air is not expelled as forcefully and completely as before; in fact a relatively large volume of air remains within the balloon.

When a disease process destroys the all important alveolar wall, several things happen. Adjacent alveoli whose walls are destroyed ‘merge’ into larger air sacks that are physiologically ineffective. The capillaries of the alveolar walls are destroyed as well. When this happens, the elasticity of the lung is severely compromised. The consequence of that is reduced air flow in and out of the lung as well as impaired oxygen delivery and carbon dioxide clearance. The patient ends up with low oxygen (hypoxia) and high carbon dioxide (hypercapnia) in the blood.

And the consequences are…

Quite devastating. I am sure everybody is familiar with the wheelchair-bound person with emphysema who must inhale oxygen from an attached tank. The reason for this should be clear by now: in previous posts we examined the role of oxygen in providing energy to the body’s cells.

Glucose is oxidized aerobically (with the help of oxygen), and provides energy in the form of ATP. When oxygen supply is limited, cells oxidize glucose anaerobic ally (without oxygen), a process that provides only a meager amount of ATP. This explains the lack of energy and limited exercise tolerance of people with emphysema. But wait, there is more!

The end product of anaerobic oxidation of glucose is lactic acid. Anybody who has done vigorous exercise knows the feeling of lactic acid accumulation in the muscles. Marathoners call it ‘hitting the wall’. Emphysema patients hit the wall after the slightest exertion. There are other complications that are out of the purview of this posting: low blood pH (acidosis) and heart failure, among others. But the root cause of all of them is low oxygen in the blood.

Who gets emphysema?

A lot of people-the numbers are truly alarming. The National Institutes of Health estimates that there are 12 million Americans with diagnosed emphysema, and an additional 12 million who have it, but haven’t yet been diagnosed.

Emphysema is the now the fourth leading cause of death in the U.S. and is expected to be the third leading cause by the year 2020. As mentioned above, the leading cause of the disease, about 80% of cases, are due to tobacco smoking. The other 20% (which translates to about 2.4 million people) is made up second-hand smoking, exposure to dust and air pollution, and a rare genetic deficiency disease (alpha 1 anti-protease deficiency).

One of the vivid pictures I still remember from my medical school days are the black lungs of two deceased people contained in a jar in the pathology lab. One lung belonged to a smoker; the other, to my great surprise, belonged to a non-smoker who lived in Los Angeles.

There is another chronic lung disease that is growing at an alarming rate due to air pollution: asthma, especially in children. The mechanism of this disease is different from emphysema, but biochemical outcome is the same: impaired airflow to the lung, low oxygen delivery to the tissues. Are there any lingering doubts about the dangers of smoking? Or air pollution?

What is being done about it?

It is amazing to me that we know the ravages of tobacco and air pollution down to the molecular level -- the science is irrefutable and beyond reproach. Yet, we had to fight the tobacco industry for many years to overcome their PR and the money they used to what amounts to bribery of our legislators. We continue to do less than is optimal to clean up air pollution. And, we still have a government that, rather than acknowledge science as a basis for public policy, uses the tactics similar to the tobacco and other vested industries to raise bogus doubts about the quality of the science and bullies scientists who simply report the facts.

Where is the outrage?

Dov Michaeli, MD, PhD