Friday, October 4, 2013

Study: Antibiotic overuse still the rule for sore throat, bronchitis | CIDRAP

Despite many years of efforts to reduce overuse of antibiotics, needless prescribing of the drugs for sore-throat patients hasn't declined in 13 years, and overprescribing for acute bronchitis has stayed about the same since 1980, according to research released today.

Using survey data from the US Centers for Disease Control and Prevention (CDC), Boston researchers reported that the proportion of sore throat patients who received antibiotics stayed at about 60% from 1997 to 2010. Only about 10% of sore throats should be treated with antibiotics, they said.

In addition, the researchers said about 73% of bronchitis patients continue to be treated with antibiotics, even though acute bronchitis is rarely caused by a bacterial infection.

The findings were presented today at IDWeek, the annual conference of the Infectious Diseases Society of America and several other medical societies in San Francisco. The sore throat study was published today by JAMA Internal Medicine, but the bronchitis study has not yet been published in a journal.

The studies were conducted by Michael L. Barnett, MD, and Jeffrey A. Linder, MD, both of Brigham and Women's Hospital in Boston.

The authors mined data from the CDC's National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. The nationally representative surveys collect data on physicians and practices, including patient demographics, reasons for visits, diagnoses, and medications.

Sore-throat prescribing gets costlier

For the sore-throat survey, the authors counted visits by adults to primary care physicians or emergency departments (EDs) for treatment of sore throat from 1997 through 2010. Patients with injuries, immunosuppression, or concomitant infections were excluded.

The survey data included 8,191 such visits over the 14-year period, which suggests a total of 92 million visits nationwide during that time, according to the journal report. Antibiotics were prescribed at 60% of the visits (95% confidence interval, 57% to 63%), a figure that didn't change over the 14 years.

In addition, "We found that there was a significant increase in the rate of prescribing broader-spectrum, more expensive antibiotics such as azithromycin," Linder said at an IDSA press teleconference today. The latter drug was prescribed at 15% of visits by 2009-10.

The only common cause of sore throat requiring antibiotics is Group AStreptococcus, accounting for about 10% of cases, according to the report. Penicillin remains the drug of choice for strep throat, Linder said.

"It turns out that the bug that causes strep throat is resistant to some of those newer, more expensive antibiotics, but never resistant to penicillin," he said. He and Barnett found that penicillin was prescribed in about 9% of sore throat cases, a figure that was stable over the 14 years.

The rate of antibiotic use for sore throat, once as high as 80%, was about 70% in 1993 and dropped to 60% by 2000, where it has remained, the journal report says. "I'd characterize that as moderate to marginal improvement and painfully slow and far from what it should be," Linder said.

The analysis also showed that the share of primary care visits prompted by sore throats dropped form 7.5% in 1997 to 4.3% in 2010.

Bronchitis data flat since 1980

For the bronchitis study, the authors used the same data sources and general methods but covered the years 1996 through 2010. They identified 3,667 adult medical visits for the problem during that time, suggesting a total of 39 million visits nationwide, according to an IDSA press release.

They found that antibiotics were prescribed at 73% of the visits overall. In EDs, the rate actually increased from 69% to 73% over the period. The appropriate rate is probably close to 0%, Linder said at the press conference.

"The really bad news is that it [the overall rate] didn't change at all over the course of the study," he said.  "Going back to 1980, the prescribing rate has essentially not changed at all."

The study also revealed that the number of visits for bronchitis to primary care doctors increased significantly, from 1.1 million in 1996 to 3.4 million in 2010.

Linder said he and Barnett had hoped for more signs of improvement, in view of the efforts to prevent overprescribing over the past 10 to 20 years. "For sore throat we're moving the needle ever so slowly, and for bronchitis we're not moving it at all. So we were surprised," he said.

Antibiotic stewardship programs have helped reduce the misuse of antibiotics in hospitals, but the findings suggest that the message isn't reaching the community, according to the IDSA press release.

Linder observed in the release that taking needless antibiotics exposes people to adverse drug reactions, allergies, yeast infections, and nausea, with no benefit.

He suggested at the teleconference that physicians need to take time to discuss the issue with patients. "The doctor assumes the patient wants an antibiotic," he said. Yet, "Other work we've done shows that patients don't actually want antibiotics as much doctors think they do."

Barnett ML, Linder JA. Antibiotic prescribing to adults with sore throat in the United States, 1997-2010. (Research letter) JAMA Intern Med 2013 (Online publication Oct 3) [Full text]

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Accompanying editorial

Tuesday, October 1, 2013

Ethical Tradition Meets Economics In An Aging China | WBUR & NPR

The sound of Buddhist chants wafts through an annex of the Songtang Hospice, the first private facility of its kind in Beijing. A group of lay Buddhists is trying to ease the passage of a recently departed soul of a patient.

When I first visited this place nearly two decades ago, the average patient stayed just 18 days. Now, it caters to people who are not terminally ill, and the average stay is about five years.

China is home to the world's largest aging population, and its attitudes and treatment of the elderly are changing. In the past, there was little mention in China of the rights of the elderly. Instead, ancestor worship and Confucian respect for the elderly were the norm.

But since this summer, Chinese law requires adult offspring to visit their elderly parents and look after their emotional needs. A number of cases of parents suing their deadbeat kids for emotional support have gotten heavy play in the Chinese media.

Law Meets Reality

Upstairs at the hospice, Huang Xuebing is visiting his mother, who has now been here for around five years and whose health is declining. Huang visits her here every day, but he still blames himself for not taking better care of her.

"In China, when you take care of a parent, you take care of him or her in your home, and you take care of them until they die," Huang says. "We call this filial piety. If you put a parent in an old age home, many people consider this unfilial. But we have no choice."

Huang says he tried to take care of his mother at home, but the caregivers he hired all quit. Huang's family comes from northeast China, and his mother's medical insurance will only pay for her treatment in her home province. So Huang uses all of his mother's pension, plus contributions from his siblings, to pay for his mother's stay at the hospice.

Huang admits he's struggling to reconcile his obligations to his mother versus those to society.

"I come here every day, but I have to take time out from work for it," he says. "When I come here to sit by her bedside and look after her every day that means that I haven't contributed to society in any other way, right?"

The challenge of caring for China's elderly is evident in the demographics. As of last year, China had about eight working-age people for every senior citizen. By midcentury, there will be only two people supporting each senior. This is because people are living longer, and they're having fewer children, in part because of China's one-child policy.

In another room of the hospice, I met a cheerful-looking 94-year-old retired teacher named Lian Yicheng. She says her daughter visits her just twice a month, and that's just fine by her.

"If there's nothing wrong, I don't ask her to come here," she says. "It's a three-hour round trip for her, so a visit takes up half her day. I tell her I'm fine, I'm alive and kicking, what's there to come over and see?"

She was separated from her children first during World War II. When the Japanese army invaded her home town of Wuhan, she fled to the wartime capital of Chongqing, then known as Chungking. She was separated from them again during the chaos of the Cultural Revolution of the 1960s, so she got used to fending for herself.

Lian believes that how each person looks after his or her parents is a matter of individual character. She doesn't think it's something you can regulate by law.

"It's something you have [to] cultivate gradually. You can't force it," she says. "My daughter has her work and her own activities. She can't live in the past, according to the feudal thinking and Confucian ways of my generation."

Holding On To Tradition

Confucianism held filial piety to be the most important ethical principle in human relations and the model for other relations; between husband and wife, ruler and minister, etc. Confucian respect for the elderly remains a powerful force in Chinese society, but it's a far cry from what it used to be.

In the past, for instance, many Chinese learned respect for the elderly from a 13th century collection of stories about 24 models of filial piety. One example is a man named Guo Ju, who was so poor he couldn't afford enough food for his elderly mother and young son.

So he decided to bury his son alive in his backyard. He could always have more children later, he reasoned, but he could never have another mother. The story ends happily, with heaven rewarding Guo for his filial attitude, so that both his mother and child survive.

A century ago, this interpretation of Confucianism was already being criticized. The idea of sacrificing a child to save a parent was lambasted as inhumane and the basis for a slavish deference to authority.

Given the residual influence of Confucianism, says Songtang Hospice founder Li Wei, the problem of caring for China's elderly is mainly an economic one, not an ethical one. He says it's not realistic to expect parents to sue their children for emotional support, and this is why there have been so few cases going to court.

"An 80-year-old who is no longer independent, who can no longer walk, how can they go sue someone in court?" he says. "It's never happened, because our citizens don't have a history of being litigious."

Li knows a thing or two about caring for the elderly. During the 1966-76 Cultural Revolution, Li served as a "barefoot doctor," treating the ill and dying with little training, medicine or equipment. Since he founded Songtang more than two decades ago, he's seen off more than 10,000 patients from his hospice. He has even named himself after his own institution and now goes by "Li Songtang."

Li argues that most of the people who bring their parents to his hospice are not unfilial children.

"The ones who are really unfilial are those who put their old folks in a coffin made of four concrete walls," he says. "They go off to do their work, and leave the old person all alone and lonely. This kind of thing happens all the time."

The Checkup - Slate and WBUR

The Checkup is a new health podcast, a collaboration between Slate andWBUR, Boston's NPR News Station. You'll find all six episodes on The Checkup's individual feed.

Monday, September 30, 2013

The story behind "Breakfast at Glenfield' - Tapas Mukherjee on Vimeo

Dr Tapas Mukherjee wanted to help his medical colleagues to learn the latest asthma care guidelines. He decided to sing the guidelines and get this filmed, and post the resulting video on YouTube. Some months and several awards later, Tapas tells his story to colleagues at the TASME Conference in May 2013 at DeMontfort University, Leicester.


Winner of the British Thoracic Society Innovation in Education Award 2012. Winner of the NHS Expo/ Network Casebook II Innovation Award 2013. is a UK social network run by its users where young MSers meet, share experiences and support each other. aims to:

• support MSers through the adjustment and emotion following diagnosis.
• empower MSers through the interaction and peer support created from our social network.
• encourage MSers to create and engage with relevant, informative and entertaining online content.
• inspire MSers not to give up on their ambitions, but to rethink how to achieve them.

UCSF First U.S. Medical School to Offer Credit For Wikipedia Articles |

UC San Francisco soon will be the first U.S. medical school at which medical students can earn academic credit for editing medical content on Wikipedia.

Wikipedia is one of the most widely used medical references in the world and the most consulted source for many health topics. But medical entries can lack reliable sources and have gaps in content.

Amin Azzam, MD, MA, will be teaching a UCSF course in which students will
contribute and edit medical information on Wikipedia.

 "Wikipedia generates more than 53 million page views just for articles about medications each month, and is second to Google as the most frequently used source by junior physicians," said Amin Azzam, MD, MA, an associate clinical professor at the UCSF School of Medicine and an instructor for the new class. "We're recognizing the impact Wikipedia can have to educate patients and health care providers across the globe, and want users to receive the most accurate publicly available, sound medical information possible."

Building Communication Skills

One of the key skills medical students are expected to acquire is the ability to seek, evaluate and interpret the medical literature for themselves, their peers and their patients. In traditional medical school courses, first and second year students are taught this skill in small group classroom sessions, while third and fourth year students are expected to apply this in the hospital wards and outpatient clinics.

"Writing and editing Wikipedia articles requires a similar skill set, and teaches our students how to write for a broader audience and communicate with patients using consumer-friendly language rather than doctor jargon," said Azzam.

Enrolled medical students will edit articles remotely, adding images, reviewing new edits, adding citations to support unreferenced text, and providing a form of peer review. Professors can track the edits and changes made to each Wikipedia page to monitor the evolution of the content.

"We know that nearly all medical students use Wikipedia. However, we want nearly all medical students to contribute to Wikipedia," said James Heilman, MD, president of the not-for-profitWiki Project Med Foundation, an organization dedicated to trying to improve Wikipedia's medical content by forming collaborations with like-minded institutions. "I see this collaboration as a very important first step in this direction, a step which will not only be beneficial for Wikipedia but will be exceedingly useful for the students themselves."  

High Demand for Quality Medical Articles

The new class is available to fourth-year medical students and will focus on editing 80 key articles that are the most frequented but have lower quality levels on Wikipedia.

All articles on Wikipedia are given a grade ranging from Featured Article, which reflects a professional level of encyclopedic information based mostly on the factual completeness of the article, to "C" which is defined as a substantial article that would be useful to a casual reader, but lacks important content. Featured articles are displayed on the main page and frequently are written by experts.

Amin Azzam explains how the UCSF elective course fits into Wikipedia's work to improve
accuracy of its information for the public.

Currently, medicine-related articles make up 58 Featured Articles on Wikipedia, and 145 Good Articles, which is less than 1 percent of the total articles in those categories, according to Azzam. "So there is a clear need to bring medicine articles up to par," he said.

The class, which begins in December, is part of an ongoing collaboration between the UCSF School of Medicine and the Wiki Project Med Foundation. For the launch of this partnership earlier this year, UCSF invited two "Wikipedians" to visit San Francisco to give lectures and run editing sessions on the significance of Wikipedia to medicine. The class has its own evolving Wikipedia page.

"As these students are going to become the next generation of health care providers we need them to be able to communicate in language that the general population understands," said Heilman. "This will hopefully help accomplish both."

UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy, a graduate division with nationally renowned programs in basic biomedical, translational and population sciences, as well as a preeminent biomedical research enterprise and two top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children's Hospital.

Conservatives launching billion-dollar free market in medical marijuana - The Globe and Mail

The Conservative government is launching a $1.3-billion free market in medical marijuana this Tuesday, eventually providing an expected 450,000 Canadians with quality weed.

Health Canada is phasing out an older system on Monday that mostly relied on small-scale, homegrown medical marijuana of varying quality, often diverted illegally to the black market.

In its place, large indoor marijuana farms certified by the RCMP and health inspectors will produce, package and distribute a range of standardized weed, all of it sold for whatever price the market will bear. The first sales are expected in the next few weeks, delivered directly by secure courier.

"We're fairly confident that we'll have a healthy commercial industry in time," Sophie Galarneau, a senior official with the department, said in an interview.

"It's a whole other ball game."

The sanctioned birth of large-scale, free-market marijuana production comes as the Conservatives pillory Liberal Leader Justin Trudeau's campaign to legalize recreational marijuana.

Health Canada is placing no limits on the number of these new capital-intensive facilities, which will have mandatory vaults and security systems. Private-dwelling production will be banned. Imports from places such as the Netherlands will be allowed.

Already 156 firms have applied for lucrative producer and distributor status since June, with the first two receiving licences just last week.

The old system fostered only a cottage industry, with 4,200 growers licensed to produce for a maximum of two patients each. The Mounties have complained repeatedly these grow-ops were often a front for criminal organizations.

The next six months are a transition period, as Health Canada phases out the old system by March 31, 2014, while encouraging medical marijuana users to register under the replacement regime and to start buying from the new factory-farms.

There are currently 37,400 medical marijuana users recognized by the department, but officials project that number will swell more than 10-fold, to as many as 450,000 people, by 2024.

The profit potential is enormous. A gram of dried marijuana bud on the street sells for about $10 and Health Canada projects the legal stuff will average about $7.60 next year, as producers set prices without interference from government.

Chuck Rifici of Tweed Inc. has applied for a licence to produce medical weed in an abandoned Hershey chocolate factory in hard-scrabble Smiths Falls, Ont.

Rifici, who is also a senior adviser to Trudeau, was cited in a Conservative cabinet minister's news release Friday that said the Liberals plan to "push pot," with no reference to Health Canada's own encouragement of marijuana entrepreneurs.

Rifici says he's trying to help a struggling community by providing jobs while giving suffering patients a quality product.

"There's a real need," he said in an interview. "You see what this medicine does to them."

Tweed Inc. proposes to produce at least 20 strains to start, and will reserve 10 per cent of production for compassionate, low-cost prescriptions for impoverished patients, he says.

Patients often use several grams a day to alleviate a wide range of symptoms, including cancer-related pain and nausea. They'll no longer be allowed to grow it for themselves under the new rules.

Revenues for the burgeoning new industry are expected to hit $1.3-billion a year by 2024, according to federal projections. And operators would be favourably positioned were marijuana ever legalized for recreational use, as it has been in two American states.

Eric Nash of Island Harvest in Duncan, B.C., has applied for one of the new licences, banking on his experience as a licensed grower since 2002 in the current system.

"The opportunity in the industry is significant," he said in an interview.

"We'll see a lot of moving and shaking within the industry, with companies positioning. And I think we'll see some mergers and acquisitions, strategic alliances formed."

"It'll definitely yield benefits to the consumers and certainly for the economy and society in general."

Veterans Affairs Canada currently pays for medical marijuana for some patients, even though the product lacks official drug status. Some provinces are also being pressed to cover costs, as many users are too sick to work and rely on welfare.

Health Canada currently sells medical marijuana, produced on contract by Prairie Plant Systems, for $5 a gram, and acknowledges the new system will be more expensive for patients.

But Galarneau says competition will help keep prices in check.

"We expect that over time, prices will be driven down by the free market," she said. "The lower price range will likely be around $3 a gram. ... It's hard to predict."

Saskatoon-based Prairie Plant Systems, and its subsidiary CanniMed Ltd., were granted the first two licences under the system and are already advertising their new products on the web.

Psychotherapy’s Image Problem -

Psychotherapy is in decline. In the United States, from 1998 to 2007, the number of patients in outpatient mental health facilities receiving psychotherapy alone fell by 34 percent, while the number receiving medication alone increased by 23 percent.

This is not necessarily for a lack of interest. A recent analysis of 33 studies found that patients expressed a three-times-greater preference for psychotherapy over medications.

As well they should: for patients with the most common conditions, like depression and anxiety, empirically supported psychotherapies — that is, those shown to be safe and effective in randomized controlled trials — are indeed the best treatments of first choice. Medications, because of their potential side effects, should in most cases be considered only if therapy either doesn't work well or if the patient isn't willing to try counseling.

So what explains the gap between what people might prefer and benefit from, and what they get?

The answer is that psychotherapy has an image problem. Primary care physicians, insurers, policy makers, the public and even many therapists are largely unaware of the high level of research support that psychotherapy has. The situation is exacerbated by an assumption of greater scientific rigor in the biologically based practices of the pharmaceutical industries — industries that, not incidentally, also have the money to aggressively market and lobby for those practices.

For the sake of patients and the health care system itself, psychotherapy needs to overhaul its image, more aggressively embracing, formalizing and promoting its empirically supported methods.

My colleague Ivan W. Miller and I recently surveyed the empirical literature on psychotherapy in a series of papers we edited for the November edition of the journal Clinical Psychology Review. It is clear that a variety of therapies have strong evidentiary support, including cognitive-behavioral, mindfulness, interpersonal, family and even brief psychodynamic therapies (e.g., 20 sessions).

In the short term, these therapies are about as effective as medications in reducing symptoms of clinical depression or anxiety disorders. They can also produce better long-term results for patients and their family members, in that they often improve functioning in social and work contexts and prevent relapse better than medications.

Given the chronic nature of many psychiatric conditions, the more lasting benefits of psychotherapy could help reduce our health care costs and climbing disability rates, which haven't been significantly affected by the large increases in psychotropic medication prescribing in recent decades.

Psychotherapy faces an uphill battle in making this case to the public. There is no Big Therapy to counteract Big Pharma, with its billions of dollars spent on lobbying, advertising and research and development efforts. Most psychotherapies come from humble beginnings, born from an initial insight in the consulting office or a research finding that is quietly tested and refined in larger studies.

The fact that medications have a clearer, better marketed evidence base leads to more reliable insurance coverage than psychotherapy has. It also means more prescriptions and fewer referrals to psychotherapy.

But psychotherapy's problems come as much from within as from without. Many therapists are contributing to the problem by failing to recognize and use evidence-based psychotherapies (and by sometimes proffering patently outlandish ideas). There has been a disappointing reluctance among psychotherapists to make the hard choices about which therapies are effective and which — like some old-fashioned Freudian therapies — should be abandoned.

There is a lot of organizational catching up to do. Groups like the American Psychiatric Association, which typically promote medications as treatments of first choice, have been publishing practice guidelines for more than two decades, providing recommendations for which treatments to use under what circumstances. The American Psychological Association, which promotes psychotherapeutic approaches, only recently formed a committee to begin developing treatment guidelines.

Professional psychotherapy organizations also must devote more of their membership dues and resources to lobbying efforts as well as to marketing campaigns targeting consumers, primary care providers and insurers.

If psychotherapeutic services and expenditures are not based on the best available research, the profession will be further squeezed out by a health care system that increasingly — and rightly — favors evidence-based medicine. Many of psychotherapy's practices already meet such standards. For the good of its patients, the profession must fight for the parity it deserves.

Brandon A. Gaudiano is a clinical psychologist and assistant professor of psychiatry and human behavior at the Alpert Medical School at Brown University.