Discussing cancer treatment with the terminal patient, KevinMD.com

“Are you giving up on me?” My patient looks at me severely. “There must be other treatment options! Aren’t there some experimental drugs out there? I have beaten this cancer twice before. Are you saying that I can’t beat it again?”

No one can ever know with absolute certainty whether my patient’s newly recurrent cancer might miraculously disappear with one more treatment. His recurrence, however, has developed very quickly and is growing very rapidly. New cancer nodules are developing weekly. I have never seen a patient with a cancer this aggressive have a meaningful, sustained response to further treatment. The research literature confirms my impression.

It is always difficult to know what to recommend. Although “no further treatment” is always an alternative, I routinely run through all of the options, reviewing whatever is available, and hoping that we land on the combination that offers that improbable, one-in-a-thousand cure. However unlikely, we sometimes set up appointments and hope for the best.

Today, though, my sense is that it is time to focus on new goals.

The decision not to pursue more studies and more treatment can be very, very difficult. Surgeon and journalist Atul Gawande in an essay in The New Yorker entitled “Letting Go,” writes about how difficult it can be for physicians and patients to halt cancer treatment as the end of life draws near. The dilemma, he concludes, “arises from a still unresolved argument about what the function of medicine really is — what, in other words, we should and should not be paying for doctors to do.” In Gawande’s view, the profession should equip and supply doctors and nurses “who are willing to have the hard discussions and say what they have seen …”

via kevinmd.com

Article continues at KevinMD.com
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Hospital meals make it difficult to control blood sugars, KevinMD.com

My mom doesn’t take any diabetes medicine.  She keeps her blood sugars normal through a combination of common sense and careful carbohydrate consumption.

A few months ago, she had to be hospitalized for what she calls a “minor procedure.”  The procedure went fine, but not the food.  The first meal they brought her consisted of breaded fish (frozen), mashed potatoes (instant), corn (canned), a dinner roll (frozen), and tea (2 sugar packets on tray).  “If I ate that, my blood sugars would have gone through the roof!” she told me.  She drank the tea, and called my dad, who arrived shortly with chopped salad, roasted peppers, and meat loaf.  This week’s post is about hospital food, if you can call it that.  You are not going to believe what it’s like to order meals for hospitalized patients.

Let’s imagine, for example, a diabetic guy in the intensive care unit.  His blood sugars have been completely out of control, up and down, up and down.  He is recovering slowly from a very serious pneumonia, and is only now beginning to eat again.  The nurse asks if I’d like to order an 1800 kcal ADA diet, which I do not.

An “1800 kcal ADA” diet means 1800 calories total each day, in accordance with the recommendations of the American Diabetic Association.  Their recommended diet is loaded (and I am not exaggerating here) with processed carbohydrate items guaranteed to make it nearly impossible to control one’s blood sugar.  No thanks.

via kevinmd.com

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Primary care needs more than 15 minutes for patients, KevinMD.com

Psychotherapy appointments have traditionally lasted 50 minutes with 10 minutes for paperwork. This has lead to the expression, “the 50-minute hour”.

More recently there has been talk of incorporating psychotherapy techniques in brief visits in primary care. The provoking title “The Fifteen Minute Hour” is from a book about addressing the emotional aspects of disease in primary care during brief appointments. The title and the concept seem relevant to much of what we do in my specialty.

In primary care we seldom spend more than 15 minutes at a time with an established patient. Yet we are required to cover infinitely more details and consider more outside authorities in every visit today than when I first started practicing medicine. Between health insurance and office administration, there are now many more mouths to feed from the office charges than there were then. Sometimes it feels like we are not alone in the exam room even for the short time we do have.

Except for doctors in concierge medicine or micropactices, most of us cannot change the amount of time we have with each patient. Even if we hope to change the system, the patients we see today deserve the best we can give them in today’s 15-minute visits.

via kevinmd.com

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25 Surprisingly Salty Processed Foods - Health.com

The average person in the U.S. consumes 3,500 milligrams of sodium a day. That’s equivalent to almost 9 grams of salt, or nearly 2 teaspoonfuls—way more than the 2,300 milligrams per day suggested by the Dietary Guidelines for Americans.

But the majority of excess salt, or 77%, isn’t spooned into your food—it comes from processed foods.

The FDA recently announced a plan to gradually scale back on salt in processed foods, which may be the end of the line for super salty products.

In the meantime, keep an eye out for excess sodium and adjust your intake accordingly. Check out these 25 hidden salt traps you can find lurking in the grocery store.

via health.com

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Beauty and Sleep Deprivation: The Science Behind Beauty Rest - ABC News

Swedish researchers say there's an important link between sleep and your physical appearance. In a study published today in the British Medical Journal, researcher John Axelsson and his team at the Karolinska Institute in Stockholm found that sleep-deprived individuals appear less healthy, more tired, and less attractive than those who have received a full night's worth of sleep.

"Sleep is the body's natural beauty treatment," Axelsson said. "It's probably more effective than any other treatment you could buy."

Subjects Photographed Before and After Sleep Deprivation

In the study, 23 healthy adults from ages 18 to 31 were first photographed after eight hours of sleep, wearing no makeup. The same adults were photographed again after sleeping only five hours and being kept awake for a full 31 hours, with the same lighting and camera settings.

via abcnews.go.com

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Shoveling Snow? How to Protect Your Back (and Your Heart) - Chronic Pain - Health.com

Snow and ice can make driving treacherous, of course, but snowfall—especially the wet, heavy kind—can be dangerous even if you never leave your driveway. Each year, shoveling piles of snow after a storm is believed to cause tens of thousands of back and shoulder injuries in the United States, not to mention several hundred heart attacks.

Overall, more than 70,000 people ended up with a shoveling-related injury bad enough to trigger a doctor’s visit in 2008, according to the Consumer Products Safety Commission. A quarter of those people visited an emergency room, and about 900 were admitted to a hospital.

The exertion, cold weather, and slippery surfaces snow shovelers face are a dangerous combination, especially if it’s an activity you’re not used to. Snow shoveling "is one of the most high-intensity exercises you can do," says Suzanne Steinbaum, DO, a preventive cardiologist at Lenox Hill Hospital, in New York City. "You’re using all your major muscle groups."

But there are steps you can take to shovel safely and ensure that you survive the winter in one piece.

via health.com

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In Praise of Nurses - NYTimes.com

I love and admire nurses.

Oncology nurses and ostomy nurses. Radiation nurses and post-op nurses. And those essential, always-there-when-you-need-them, round-the-clock nurses. (And though most of my experience is with female nurses, I admire male nurses, too.)

Now this isn’t some abstract infatuation, based on seeing “South Pacific” one too many times. I’ve been hospitalized six times in my life, and the medical personnel I came to know best — and like best — were the nurses.

To generalize: Nurses are warm, whereas doctors are cool. Nurses act like real people; doctors often act like aristocrats. Nurses look you in the eye; doctors stare slightly above and to the right of your shoulder. (Maybe they’re taught to do that in medical school?)

My most recent dependence on nurses came in 2008 and early 2009 as I was treated for an aggressive Stage 3 prostate cancer. But more about that later.

via well.blogs.nytimes.com

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Study: Surgical Delays Have Profoundly Adverse Impact | National Nursing News

A new study emphasizes why caregivers must work to minimize delays in certain elective surgical procedures for patients who have been admitted to the hospital.

Delays substantially increase the risk of infectious complications and raise hospital costs, according to a comprehensive study in the December issue of the Journal of the American College of Surgeons.

Using a nationwide sample of 163,006 patients ages 40 and older between 2003 and 2007, the authors evaluated patients who developed postoperative complications after one of three high-volume elective surgical procedures: coronary bypass graft, colon resections and lung resections.

For each type of procedure, according to the researchers, infection rates increased significantly from those performed on the first day of admission to those performed a day later, two to five days later and six to 10 days later. With each procedure, there was a difference of at least 10 percentage points between infection rates performed on the day of admission and those performed six to 10 days later.

Delays also increased total hospital costs from $36,079 to $47,5237 for CABG, $20,265 to $29,887 for colon resections and $26,323 to $30,571 for lung resections.

The occurrence of infection after surgical procedures remains a major source of ill health and expense despite extensive prevention efforts via educational programs, clinical guidelines and hospital policies, according to the researchers.

The analysis “confirms a direct correlation between delaying procedures and negative patient outcomes,” lead author Todd R. Vogel, MD, MPH, FACS, assistant professor of surgery at the University of Medicine & Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, said in a news release.

“As pay-for-performance models become increasingly prevalent, it will be imperative for hospitals to consider policies aimed at preventing delays and thereby reducing infection rates.”

Patients more likely to experience in-hospital surgical delays were age 80 and older, female and minorities. They had existing health issues such as congestive heart failure, chronic pulmonary disease and renal failure.

via news.nurse.com

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Jonas Center Quantifies Impact of Nursing Faculty Shortage | All Sites Nursing News

The shortage of nurse educators could affect the care of millions of patients, according to estimates by the Jonas Center for Nursing Excellence.

Each nurse educator position left unfilled could impact healthcare for 3.6 million patients, according to the report. Schools with baccalaureate nursing programs have about 900 faculty vacancies, with thousands more likely to arise in the next 15 years.

Darlene Curley, RN, MS, executive director of the Jonas Center for Nursing Excellence, and Christine Kovner, RN, PhD, FAAN, professor at New York University College of Nursing, developed a formula to measure the impact of nursing faculty vacancies on patients. They considered the average number of students taught by one faculty member and the number of patients cared for by a typical RN. They note that their estimates are conservative.

via news.nurse.com

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7 Biggest Diet Myths | LiveScience

Bathing suit season is just around the corner and every friend has a new diet tip. But does science back them up? Here are some of the most popular diet myths that make scientists shake their heads.

--Robin Nixon, LiveScience Staff Writer

via livescience.com

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