Family Medicine Notes

Well, in the context of writing not one but TWO prescriptions for antibiotics in the last 24 hours (long-time readers will recall that I am a fanatic about the overuse of antibiotics and I write for them very rarely)

This time, I had a reason.

Our local version of the pertussis outbreak has become signifiant.  With 21 confirmed cases in a high school about 4 miles from our office, I treated a coughing student from that school this morning after consultation with the health department.   But last night's customer was a textbook case.  The PCR's will be back in a few days. We'll see.

In realted news ...

This study in JAMA confirms that a shorter duration of antibiotics may be better in the ICU:

• CONTEXT: The optimal duration of antimicrobial treatment for ventilator-associated pneumonia (VAP) is unknown.
• Shortening the length of treatment may help to contain the emergence of multiresistant bacteria in the intensive care unit (ICU).
• RESULTS: Compared with patients treated for 15 days, those treated for 8 days had neither excess mortality (18.8% vs 17.2%; difference, 1.6%; 90% confidence interval [CI], -3.7% to 6

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With holidays around the corner -- Sam's made some revisions to the Sock of The Month Club -- and in doing some "market research"  we learned that there are only 6 days left to purchase these on ebay ... a bargain at any price.

Posted by Jacob Reider, MD at 01:52 AM | Permalink | Comments (1)

Posted by Jacob Reider, MD at 01:22 AM | Permalink

The Medicare prescription drug program stinks.  I don't quite understand why AARP supports it.  Many seniors will get LESS benefits under the program.    Here's a report (pdf) that explains some of the reasons that we shouldn't support it.  Our local newspaper published an editorial this week against it, and I am impressed with their insight.

From an article in the Kansas City Star:

Meanwhile, a dozen AARP members gathered outside the organization's Washington headquarters to protest the decision of the large seniors' group to support the Republican Medicare proposal. Some tore up their membership cards.

"I always felt like they were for us," said Queenita Gaskins, 67. "I cannot believe that they want us to go with something that isn't for seniors." Gaskins criticized what she said was the bill's skimpy coverage of drug costs; the package would offer no coverage, for example, for costs between $2,200 and $3,600.

"This bill is terrible, just terrible," added Evelyn James, 85, as she stood outside the AARP building in pouring rain. "This offers nothing for seniors and will diminish our health services."

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Faughnan's Notes mentions an article in the economist on beta blockers and memory. 

The mood and memory effects of beta-blockers are subtle, and despite some reviews in the medical literature, I do believe that this is clinically significant.  INdeed, the fatigue associated with carvedilol seems to be greater than that associated with older agents. 

Today I saw a patient who has been on carvedilol for about 10 months - and her ejection fraction has improved from 30% to 55%.  But she's terribly depressed and feeld so fatigued that she can't do anything.   

The SSRI has done rather little  - and today I called her cardiologist and we agreed to stop the cavedilol for a month or so and wee what happens.  

A 45 year old with hypertension felt that the metoprolol was doing fine.  But after a bit of careful discussion and a zung scale - I learned that he had depression.  This is the trouble with much of behavioral medicine.  Since the medication isn't discontinued - the problems are very likely more common than the studies suggest.

Posted by Jacob Reider, MD at 12:13 AM | Permalink

Back to Medical Informatics this evening ..

a) There is a new report out from the GAO.  It's 120 pages long, but worth the download if you're intersted.  Here's the overview:

The rapidly rising costs of health care, along with an increasing concern for the quality of care and the safety of patients, are driving health care organizations to use information technology (IT) to automate clinical care operations and their associated administrative functions. Among its other functions, IT is now being used for electronic medical records, order management and results reporting, patient care management, and Internet access for patient and provider communications. It also provides automated billing and financial management.

The Ranking Minority Member of the Senate Committee on Health, Education, Labor, and Pensions asked GAO to identify cost savings and other benefits realized by health care organizations that have implemented IT both in providing clinical health care and in the administrative functions associated with health care delivery. GAO analyzed information from 10 private and public health care delivery organizations, 3 health care insurers, and 1 community data network.

b) In my discussions of the AMIA meetings from last week - I didn't discuss two topics that were more important than I expected.

1. CCR.  I mentioned it briefly last week (and last May) but it deserves more explanation. CCR is an attempt to develop a minimal data set that would provide enough data for a patient to be adequately cared for in a new setting.  Ideally thought of as a "transfer record" - it's become more than that over the last 6 months, and remains a work in progress.
   
   CCR is controversial.  Many argue that HL7 could do this just fine, and that there is no reason to develop a NEW standard - where augmentation of the existing data transfer standard would suffice.
   
   But maybe it wouldn't - and maybe we need to agree on what this minimal dataset is before 2015 - as HL7 (the organization) moves rather slowly.
   
   So with the framework of ASTM and the support of HIMSS and the Massachusetts Medical Society, CCR is building steam.  A measure of this steam is the fact that the AAFP project (and all of the vendors who have signed on with that project) has embraced CCR as a method of sharing data across systems.
   
   Hmmm ... While this is intuitively good, it's also risky at this point for anyone to be certain that this is good, since the definition of CCR remains up in the air.  the drafts I've seen have had weaknesses - depending on the perspective of the reviewer.  The balance betweek keeping it simple (and therefore easy to implement) and keeping it complete (thereby capturing all of the important data) is a tricky one.
   
   CCR will be defined in XML.  This is no big deal - and is certainly the appropriate way to express it.  What's nice about XML is that the data can be transformed very easily depending on how the user wants to see it.  If you're curious what in the world I'm talking about - you may need a tiny intro to XML  Here you go.  Just read the 1st page -- shouldn't take you more than 2 minutes.  I'll wait here until you come back.
   
   Ok .. so we all "get" XML now.  See .. it's really pretty simple and indeed that is the goal of CCR.  To define a patient record in a simple way so that we can transfer care quickly and easily.
   
   Microsoft is building new XML tools such as InfoPath.  They understand that healthcare is the right kind of business to market this stuff to.  Here's an interesting demonstration of Infopath:  The Microsoft Office InfoPath 2003 HL7 CDA Demo.
   
   Should we start interrogating our vendors on whether they support CCR?  No .. not yet .. but if they haven't heard of CCR at all - we may want to give them some homework.  To get more involved in the CCR project and review drafts, give input, etc .. join ASTM.
   
2. Along similar lines, there is a confusing project now going on within HL7.  When many people think of HL7, they think of the protocol that defines transactions.  IN fact, HL7 is an organization and within this organization, there are a group of people who are trying to answer a question that the government has charged them with answering:  what is an electronic health record?
   
   It's and important question - since the answer will ultimately define a set of standards that will, one hopes, provide better uniformity in how these systems function.  Think of medical records in our practices and hospitals like money in banks.  It doesn't really matter to the banks how the money is stored electonically.  I'll bet that the database at Bank of America looks different from the database at Wells Fargo.  But since the banks have all agreed on how the money will go out and come in ... my money can move from one bank to another pretty well.  The standard that defines how the money moves is like the HL7 standard for transactions --- and in some ways, like the CCR.    My bank account is like my electonic health record.  If we can't agree on what a bank account (electonic health record) is, then it's going to be hard to form the standard for the transactions between the banks (healthcare providers).
   
   So what?  well .. if one system understand the concept of "family history" and the other one doesn't .. then the system there is no way that this data is going to come across from one system to the other.  So we have to define what the systems will be able to understand.
   
   This is what the HL7 EHR functional Model  is. 
   
   I went to a session hosted by the HL7 folks.  It was billed as a "town meeting" but was rather sparsly attended.  For two hours, we argued about what an EHR is, and how it should be described.  I was especially impressed with the insight of Don Nelson.   (scroll down to see Don)

Posted by Jacob Reider, MD at 01:56 AM | Permalink

Hey - John's got a weblog -- er -- three.

• Faughnan's Notes.  - Friends and family
• Medical Notes - the medical version
• Quick Notes - quick notes blog

I missed John at AMIA this year.  His weblogs are great.  Hmm .. he's uing blogspot -- so no RSS.

Posted by Jacob Reider, MD at 02:55 AM | Permalink

Over at LMN: Live from the 2003 Fall AMIA Conference.  This is Ignacio's version of  the EHR session.  He types faster (and has better batteries) than I do.  Neither of us liked what we heard -- but for different reasons, it seems. 

I'm not bothered at all about the code.  Open source of the code that's behind the software is simply unnecessary.  Good software can be "closed source" and still be good.  The key is that our data be accessible.  With many EMR's the data is locked forever.  It's a real problem and dates back to the age of the dinosaurs. 

A key (and laudible) component of the AAFP project is that the data remain accessible.  

Posted by Jacob Reider, MD at 02:50 AM | Permalink | Comments (1)

So it seems that Docusate Sodium (Colace) does rather little. Despite this, it remains the mantra for post-partum care (with the partner FeSo4).  This isn't recent news.   I wonder why it's still used so much?

Nonetheless -- I suggest it frequently -- for problems at the other end.

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An interesting letter from Rick Peters on the AAFP Open EHR from last April.  Much has changed since then.

Here's a pair (one  two) of press released from this week.

OK .. so we learned about who the vendors are:

• A4 Health Systems - EMR
• GE Medical Systems Information Technologies - EMR
• HP -Hardware
• MedPlexus - EMR
• MedPlus, Inc - Interfaces
• NextGen - EMR
• Physician Micro Systems  - EMR
• Siemens Medical Solutions - hosting, infrastructure
• Welch Allyn -  instruments

Most of these are no surprise. 

I didn't anticipate Medplus or Welch Allyn.

A Definition of the "ACID" test - as I described a few days ago:

• Affordability - Recognizing the limited capital available to family physicians in small medical practices, the AAFP's partnering firms will discount their prices and work with the AAFP to increase the volume of their sales for software and hardware.
• Compatibility - Compatibility will be achieved through efforts to standardize connectivity interfaces between office-based systems, such as the EHR, and key information resources for electronic prescribing, laboratory result reporting and hospital information systems.
• Interoperability - Interoperability standards, such as the Continuity of Care Record, will be jointly developed by the AAFP and partnering companies to permit seamless data exchange among physicians, other providers and patients.
• Data stewardship - Data stewardship will become an increasingly important challenge as larger amounts of physician-generated health information are collected, stored and managed in systems and databases across the country. These data must be protected, kept secure and used only for ethical purposes that support the highest values of the medical profession.

... and a search of google for "AAFP EHR" brings up Family Medicine Notes in the top five.

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The last session in this afternoon's adventure is a discussion of how OCR was used to populate an EMR.

It's a good talk.

He reviews how a paper template can be used to provide decision support and improve the quality of data entry.

They developed the concpt of "adaptive turnaround documents."

Aftern the patient checks in, a form is generated (based on a patient questionnaire that the patient fills out -- and patient demographics) that the nurse and then the physician will fill out.  So the clinical staff get a custom developed form that helps them focus on issues that the rules engine thinks are important. 

Cool

So the kid with asthma gets a different form from the adult with diabetes.

Workflow:

1. Patient checks in
2. Patient gets the survey
3. Nurse gets the patient (with the form)
4. Nurse gets the form and scans it into the "Digital Sender" (HP4101mfp) and the device e-mails the scanned image to the OCR server.
5. System reads the form and determines it slevel of confidence about each item.
6. The system then creates a form based on the inputs from the patient survey

They did a fairily thorough of QA and observation of how the system worked from a workflow standpoint.  Research findings:

1. 224 forms completed in a 6 day study period
2. 98% or so were completed
3. 98% were accurately scanned
4. It took 25 seconds to generate the form
5. 43% of the forms required some correction
1. The software prompted the nurse for corrections and/or confirmation - the average was about 1 .4 fields per form. 
2. This took about 10 seconds per form.

Soooo ..

Here's the punch line .. they can now alert the doc to clincial problems.   The doc is prompted:  "John has a BMI of 12 - you may want to consider malnutrition."

Interesting.  He's got other thoughts about faxing forms to teachers for ADHD evaluation, etc.  Cool.  Medical Informatics with paper.

Posted by Jacob Reider, MD at 03:13 PM | Permalink | Comments (2)

Now I'm at Octo Barnett's session.  He's at MGH - the medical mecca back in Boston.  Indeed, he's an icon of Medical Informatics ... has been doing this work since most of us were toddlers.

It's an interesting talk on how they built an intranet for primary care physicians in Boston that was very successful.  No surprise there.  Formulary infomation, Up-to-date, referral forms, how-to, etc. etc.  To support this system, they have several FTEs - including a 1.5 FTE clinicians.  Big resources that only MGH or another big organization could afford.  They develop content, support old content ..

Then they did a cool thing:  they went out to places that had no such infrastrucutre - rural Maine, Rural Arizona, Nashville, etc. 

The goal of this was to see if it met Octo's three-pronged "reality test"

• Is it used by real people for real jobs?
• Is it supported by real money?
• Can it work somewhere else?

Now .. does an "intranet" with such clinical information work well in other environments?  The answer is maybe.  There are things that need to be localized:

• Formulary
• Patient Education Information
• Referral Information
• Guidelines

Other barriers included hardware and software availability.  Some of the sites had insufficient hardware, connectivity or technical resources to implement even the end-user side of this.  Without good Internet access - one certainly can't use web-based resources.

Overall - the session was a good descriptor for how one could succeed in implementing a clinical web resource - but many questions about sustainability (the project was funded by an NLM grant) remain.

----------------------------------------

Next is a paper on whether the EMR is trustworthy.  This is interesting too.  The issue involves the ease with which one can copy stuff.

"It's very easy to use ctrl-c and ctrl-V to create your progress note"

The concern was bred from the observation that some progress notes in the VA EMR were VERY similar to previous notes.  Are the physicians generating real records .. or just copying the previous notes?

They uised to "Copyfind" by Louis Bloomfield, which is open source, and was customized to read records from the EMR.

Then they looked for notes that had exactly the same text for 40 words, and then scored these events on a scale of risk.

Of 167,000 notes, there were 90,000 "copy events" identified by the software.  Some of this is a product of templates - and so may not represent "real" copy events.  They "dug down to about 6,000 notes on ~250 patients to look closely at what was going on.

8% of notes had copied text in them

1% had copied text of some risk

0.1% had copied text of high risk.

The prevlance of copied text was rather high - roughly 10% of patients had copied text in their records.

What parts of the record was copied?

1. Problem list
2. HPI
3. PMHX
4. Meds

What was high risk copied sections of the chart?  Physical Exam.

Summary: 

1. bad copying does occur
2. We don't know why (not yet studied)

How can we stop it?

• Revide Templates
• Minimize inserted data
• Develop hx and exam objects for review and re-use
• Enhance problem list function
• Educate staff on the copying issue and how copying erodes trust of the medical record and that it can be detected
• Adopt policies that inappropriate copying in not acceptable

This was an interesting session that I really did enjoy.  He's honing right in on why/how the EMR needs to be well designted to optimize data entry.  The fact that physicians copied test into the record demonstrates that novel clinical observations are too time consuming to record.  While one may think that this paper is an indictment of the users ... I don't think that's the right way to look at it.  Remember Rule 1 of software development and implementation:  Don't blame the user.  If they are doing something wrong - it's the developer's responsibility to make the system better so that the proper use of the system is easier than using it "wrong."  

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Hmmm  Next paper is too dry for me.  Time for a nap.  I think I'll check my e-mail.

Posted by Jacob Reider, MD at 02:34 PM | Permalink

Yesterday we learned that the AAFP board decided not to join NAPCI.  Like many family physicians, I don't understand why. 

NAPCI, which was the brainchild of two family physicians, is an effort to unify the voices of primary care physicians.   Despite the fact that primary care physicians provide the majority of medical care in theis country, hospital information technology needs have been the primary drivers of most of the standards and policies that healthcare IT vendors attend to.  Without standards for primary care information technology - the mishmash that now exists will continue.   To say that it is challenging for a primary care physicians to make good choices about buying an electronic health record in their office would be an understatement.  Feature matrices, functional requirements, usability metrics .. etc etc etc .. it's all so complex and there is no unified message to the government on what primary care needs .. nor is there a unified message to the vendors.

But NAPCI - which now has been formally created - aims to change that, and I have high hopes for what it will accomplish.  Yet when David Kibbe explained to me that "AAFP has decided not to join at this time."  I realized that what seems so self-evident to most of us (that collaboration among the primary care specialities would be a good thing) is perhaps not so clear to some others.  

Here comes the hard part:  I can't help but wonder how much of the AAFP board's decision had to do with the messenger rather than the message.   What does David Kibbe have against NAPCI?  It's possible that in the context of his own efforts to play a role in the shaping of public policy and vendor policy through the AAFP's new Center, David wants to be the only such voice for primary care - rather than either sharing the podium with NAPCI or working through NAPCI. 

Perhaps he'll weigh in at some point and help us understand that - but it's ironic that he was rebuffed by the other primacy care specialities when he approached them about joining the AAFP EHR project last Spring .. yet now when they have all agreed to work together through NAPCI - he turns his back on them.  As a family physician and an AAFP member - I WANT the AAFP to join NAPCI - since I think that NAPCI is the best conduit for getting these groups to work together.  Indeed, had David engaged NAPCI last spring, it's possible that the EHR project may have been more readily embraced.

Alan Zuckerman told me last night that the AAP has been surprised that David hasn't continued to engage them in the EHR project - and I've heard that SGIM and ACP have similar feelings.  

It's all troubling because I do want the AAFP EHR project to flourish - and I suppose that working with other groups could be perceived as a potential roadblock in the path of moving the EHR project along swiftly.  

Who knows.  On my end -- along with this well-kown genius - I'm going to begin lobbying AAFP to reconsider their decision.  If you know an AAFP board member - or are active in your state Academy of Family Physicians - please do your best to send this message:

Posted by Jacob Reider, MD at 09:18 AM | Permalink | Comments (2)

Still at the AMIA meeting in Washingotn DC.  This afternoon there is good wireless access in the conference room -- unlike the morning.

I'm now at a session hosted by Alan Zuckerman.  Alan is a guy who seems to have lots of energy and is always working on yet another project.

Other presenters at this session include David Kibbe - who is the architect of the AAFP EHR project - and Michael Bainbridege.  Mike is from across the pond - and worked for Meditel (now Torex).  Mike is chair of the BCS Primary Health Care Specialist Group. 

The title of this session is:

"A phoenix Rises from the ashes of Open Source: Lessons learned and New Directions Taken"

I suppose this refers to the Oceana product I've discussed before ... that's the phoenix.  Now the product has been transferred to Medplexus.

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Notes from David Kibbe's talk:

• Nine Technology Companies will announce a coalition arround a set of principles (see ACID from yesterday)
• History:
  • 1/2001 - AAFP board of directors agreed that by the end of  2003, all of family physicians would be using the Internet in their practices, and by 2005, xx% would use an electronic health record.
  • In fact, by now - many (?85%?) are using the INternet by now .. but there has not been a significant move to the EHR .. roughly 9% are using EHR now.
  • Rick Peters and David had been talking about open source .. so brought to the AAFP the completed application that Rick had written as Oceana (now Medplexus) .. and suggested theat a new not-for-proft coropration be created to develop and maintain this open source EHR.
  • Bottom line is that the AAFP could not do this on their own and then they went to the other societies (AAP, ACP, SGIM, ACOG, etc) and tried to get their involvement.  The didn't sign on - so AAFP was left needing to make a decision about what to do.
  • This was 6/2003.  AAFP had engaged its members ("over 6,000 AAFP members had contacted me and said that this was a good idea") - as well as CMS and some potential industry partners.
  • So now what to do?  AAFP felt that they needed to move forward -- and found lots of industry support ("Java programmers and XML programmers came out of the woodowrk to help us develop an open source EHR")
• So . what to do?

Meetings started with big companies "that you would recognize."

• Who is this?  He didn't say .. "nine companies" 
  • hmm .. what we've heard on the street ..
    • GE
    • Siemens
    • PMSI
    • HP (hardware)
    • IBM
    • NextGen (?)
    • hmm ... who else? 
• What to do?
• Principles (this is the ACID test mentioned yesterday). 
  • David is discussing this at length - but isn't really giving us any more than we had yesterday.  It makes sense .. and is all just fine- but is really rather global - and within the ACID principles -- there remains a great deal of ambiguity. 
  • The "Data Stewardship" issue is important - and David reminds us that it is of paramount importance to the
• Unformity of data transfer methods.  He's telling us that CCR "will be a breakthrough continuity of care standard - done in XML."
• "Open source is being replaced with a model of guiding principles and open standards."

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Alan Zuckerman is now talking.  He's more focused on the "open source" discussion.

The original goal of the project was to take an open source product - and fund the installation and development.

What is an EHR? 

ooh ... low battery .. more later .. better post this for now ..

 http://www.doh.gov.uk/ipu/

Posted by Jacob Reider, MD at 03:32 PM | Permalink

Today is my second day in Washington DC.  Yesterday was the STFM communications committee meeting.    These all-day meetings can be a challenge - as it seems that everyone gets kinda antsy toward the end of the day.  We got a fair amount accomplished.

Now I'm at the AMIA Primary Care Informatics Working Group meeting.

Bob  Phillips from the Graham Center is talking about the new project of the Center for Health Information Technology. - specifically the AAFP's EHR project.  There will be a press release next Wednesday morning on the project - and how the flavor has changed a bit - with less of an emphasis on open source, and more of an emphasis on vendor openness.  The "acid test" to define which vendors would be involved is as follows:

ACID test:

A = affordability. 
C = Compatible.  The systems must be compatible with each other and vendor lock needs to be avoided.
I = Interoperability.  The data must be stored in a manner that permits access regardless of system or hardware.
D = Data stewardship.  The data  must remain owned.

Hmmm.  This is tough to interpret, and its not clear to me exaclty what this really means.  Tomorrow Alan Zuckerman is holding a session on the project and I think we can build a more detailed understanding of it then.  David Kibbe has held these cards rather close to his chest - and in this absence of transparency - it's hard to trust that what he's doing is the right thing.  I do trust Alan - and I'm curious how he's been able to engage David in such a detailed fashion.  I look forward to learning more from him.

Bob's next topic was a discussion of a statement that will soon be released by NAPCRG at their recent meeting in Banff.

The short version is that NAPCRG wants the US to embrace a coding system that makes sense to primary care physicians, and that they feel that ICPC-2 is the right answer rather than SNOMED-CT.

------------------------------

Now David W Bates is talking about the NAPCI project.  It's an effort to pull primary care together to provide one voice toward the unification of efforts in primary care informatics.  The NAPCRG statement is a good example.  NAPCRG will be one of the members of NAPCI.  While it's good that NAPCRG releases a statement on coding, it would be much more meaningful if such a statement came from NAPCI- representing all of primary care.

David is also discussing the IOM EHR report - which is a must-read for anyone thinking about these topics.

David  a good speaker - and clearly has a good vision for where this stuff ought to go.  He's urging us to become involved in the HL7 EHR project.  This is a big project - and it's not clear that it's going in the right direction.  The vendors hold a great deal of control in HL7 - and while this project is uniqie in that the cost of becoming involved is only $100 - it's still not clear to me what the content of this proposal is.  There will be another draft of the "EHR DSTU" released here at the AMIA meeting tomorrrow night.  Hmm.

In addition to the national efforts, David is reviewing a project that he's leading in Massachusetts. The goal of the project is to build and fund a state-wide initiative that would enhance the implementation of electronic health records in primary care practices in Massachusetts.  Core concepts include data exchange (meds/labs/radiology) (?? problems & allergies??) - along with the selection of a few EMR vendors to guide physicians in the appropriate selection fo software and hardware.

The Massachusetts project will be a good model fro what NAPCI may be able to spread to other states.

Other next steps for NAPCI will be to become more involved in the NHII project, to provide tools that practices may be able to use to make decisions about EHR adoption.  Such tools may be ROI calculators - or guildelines about features/functions etc.  Seems like AAP and ACP may have some of these tools developed - as does AAFP.  Our goal would be to catalog these tools and perhaps edit them so so that they meet all of our needs.

Other notes/links relevant to David's talk:

DOQIT (I can't find a link defining this right now ... but at least this is a placeholder)

EHR Collaborative

AMIA Primary Care Working Group position paper

--------------------

Comments from the audience: 

What are the unique needs for IT in primary care?  Do we know?

• David:  Not yet - and in fact this is what we are working on establishing. 
• Lost of discussion now about NAPCI and what it is and what it will become.  David says that there are an awful lot of moving parts here.  Can we influence the standards bodies? 
• A mention of Leapfrog.  They're going to release their next "leap" in a few weeks.  Focus: Primary care.

Posted by Jacob Reider, MD at 11:24 AM | Permalink

Henry Ford Health System's PR website has a blurb:

This looks like an interesting study but it's not yet published.  Some of the findings:

• By age 7, children given at least one antibiotic in the first six months were 1.5 times more likely to develop allergies than those who did not receive antibiotics. They were 2.5 times more likely to develop asthma.

• By age 7, children given at least one antibiotic in the first six months and who lived with fewer than two pets were 1.7 times more likely to develop allergies, and three times more likely to develop asthma.

• By age 7, children given at least one antibiotic in the first six months and whose mother had a history of allergies were nearly twice as likely to develop allergies.

• By age 7, children given at least one antibiotic in the first six months and who were breast-fed for more than four months were three times more likely to develop allergies. However, breast-feeding did not influence the risk between antibiotics and asthma.

“I’m not suggesting children shouldn’t receive antibiotics. But I believe we need to be more prudent in prescribing them for children at such an early age,” Dr. Johnson says. “In the past, many of them were prescribed unnecessarily, especially for viral infections like colds and the flu when they would have no effect anyway.”

Dr. Johnson theorizes that use of antibiotics may affect the gastrointestinal tract and alter the development of a child’s immune system.

Posted by Jacob Reider, MD at 12:36 AM | Permalink

The Health Care Blog brings up the Crestor issue.  The AZ rep was in our office the other day and I couldn't help but mention the Lancet article.  He had a scriped response.  "we're thinking of a lawsuit against Lancet - many of thiose statements were innacurate."  uh .. ok .. but how about the safety concerns?    He reassured me that the safety profile was similar to Pravastatin. 

We'll see.

Posted by Jacob Reider, MD at 12:31 AM | Permalink

The American Academy of Dermatology has a good patient information handout on Scabies.  It's very well done, and provides useful into. 

I'd like to give it to patients .. and I sometimes do .. but I usually hesitate - or read them sections I don't agree with.  Like the treatment:  "See a dermatologist as soon as possible to begin treatment."

Huh?  Why would it be necessary to see a dermatologist to treat scabies?  Primary care physicians see and treat scabies every day. 

Alas -- the line between marketing and medicine blurs once again.  Sure .. the American Academy of Dermatology is gonna suggest that people see a dermatologist.  No surprise there, I suppose .. but is it good medicine?  In fact, I think that it's WORSE medicine than seeing the primary care physician.  We treat the whole family ... and scabies is one that can certainly get the whole family.

So the advice of a specialty organization suggests that patietns do something that is better for their business but worse for patient care.  How hard would it have been to say "see your physician" instead?

Posted by Jacob Reider, MD at 11:16 PM | Permalink