12%

So it's been awhile since I posted, and that's mostly because I don't really know what I want this blog to be in the future. Since I have started my first NP job, it's tempting to post about interesting cases I see there. But there are lots of other medical blogs that already do a similar thing very well. So, I think for the time being, I will continue to post very, very sporadically, more or less as I am inspired to write. The story below is pretty, ahem, inspirational.

I had an admission yesterday who completed of chest pain. Although he put it at about 6/10, he said it had been around for awhile, was more or less constant, and had no other cardiac symptoms. He had never had it worked up before and was able to converse with me at length without any outward signs of discomfort or anxiety. So, almost certainly not a heart attack, or even angina. What he did have was a number of respiratory symptoms, and a 20 year history of smoking half a pack a day. EKG normal. Signficant wheezing bilaterally in lower lobes. Physical exam otherwise normal. Blood drawn after.

I spoke with the patient about the fact his discomfort was likely due uncontrolled asthma or COPD. I said that he would need appropriate treatment, and might need further cardiac evaluation. I offered him the option of signing up for primary care at ARTC, but he declined, opting for a provider at North General Hospital. Fine. I wrote a referral to his future internist, explaining our findings, emphasized that to him that he should see his doctor soon, and referred hom for a chest x-ray.

This morning he is in my office for a dose eval. I asked if he had gotten his insurance sorted out and the CXR done. He told me he had instead gone to the emergency room. I asked why, he said "the pain in my chest". I reminded him he had had the pain yesterday and for months prior; what made him decide to go to the ER last night? He looked at me blankly before understanding, and stated halfheartedly, "It got worse." He was, however, pleased with his care. After all, they had done an EKG, bloodwork, and a chest x-ray. Then they had written him a referral for follow-up care.

Aaargh. I can't shake the feeling he went to the ER because I scared him by telling him something was wrong with him, but he didn't want to go through the administrative hassle of signing up for an actual primary care doctor, who almost certainly would have started him on appropriate care and referred him to a cardiologist. But now, he's been worked up twice in the same day for the same symptoms, and he still doesn't have an MD to prescribe what's needed for his asthma/COPD. So basically more dollars have been spent, and the overall result was worse.


American medicine is like 12% of GDP and yet our life expectancy is shorter. Stories like the above are why.

nyc's sugar-betes

Hope everyone's having a happy holiday weekend!

Two diabetes-related pieces of news have surfaced recently. One: unfortunately, diabetes is on the rise in NYC. According to a November 2009 report from the NYC Department of Health and Mental Hygiene, diabetes is up 13% from 2002. It is more prevalent in men than women, and in those without a high school degree than those with a diploma. Interestingly, the death rate from diabetes has not moved since 2002 (it was then and is now 18 deaths per 100,000 New Yorkers) but it is likely to be underreported. As most reports on diabetes have noted, the illness disproportionately affects African Americans, Hispanics, and those from low income neighborhoods.

The other interesting item is that NYC's Health and Hospitals Corporation (the largest public health care provider in the country) has recently launched an online program to help the 58,000 diabetics under its care. The site features advice on how to control diabetes by eating healthfully and exercising. The site also features some patient success stories to motivate readers.

just in case...

I have been told I have seemed anti-vaccine as I have blogged about the mandatory H1N1 and flu vaccines for health care workers (HCWs). I did pause over the notion that something like this could be mandatory for half a million people, many of whom explicitly stated they did not want it, for me the central issue was not rights, but efficacy. To me, if the two vaccines had been proven to be very effective in preventing transmission of the flu, it would be justified to require health care workers to get them. Similar logic has been applied to the MMR vaccine, which is mandatory for NYS HCWs, despite challenges in court. However, if the efficacy was low or even not well established, I thought requiring it would be wrong

The logic of the mandate was that HCWs who got the vaccine would be less likely to transmit flu to their patients than non-vaccinated HCWs because their immune systems would be better equipped to fight off the infection. I was unable to find any studies addressing this point explicitly. However, I did find an article in the September issue of the New England Journal of Medicine addressing the overall effectiveness of the flu vaccine. The article was especially interesting because the objection I have head most to the flu is, "how well does it work in young, healthy people?", and participants in this study were all between 18 and 49 years of age. In fact, the mean age of participants was 23.3 with a standard deviation of 7.4 years. That said, no one was excluded from the study on the basis of health unless they had a condition for which the flu vaccine was contraindicated.

The study's intention was to compare the efficacy of the inactivated virus vaccine to the live virus vaccine. The 1952 subjects, all eligible to receive either vaccine, were randomized into two groups. Within these groups, 5 out of every six people received a vaccine, the sixth received a placebo. INTERESTINGLY, each of the vaccines contained three strains of flu, two type As and one type B. One of the type As was H1N1. Subjects were told to follow up if they had a respiratory symptom (stuffy nose, cough) combined with a "constitutional symptom" (fever, malaise). If and when they did, the organism infecting them was cultured.

In the end, 119 participants came down with the flu. One had H1N1, and the others were infected with either the other A strain contained in the vaccine, H3N2, or a B strain that was not in the vaccine. The efficacy of the vaccine with inactive virus when compared to the efficacy of placebo was 73%, the efficacy of the active virus compared to placebo was 51%. Obviously, the inactive vaccine was the more effective of the two.

So there you have it. If you get the inactive flu vaccine, even if you're young and probably healthy, there's a significantly smaller chance you'll get the flu than if you don't. To what extent this translates to a diminished likelihood of transmitting it to someone else is still unclear, although the inference that it would lead to a significantly diminished transmissions is more plausible in light of this rate of efficacy. Frankly, the results were more dramatic than I anticipated, and while I'm still not sure I agree with mandating the flu shot, I am more sympathetic to the idea than I was before seeing these results.

whew

So it's been awhile since I last posted, and the main reason for that has been that I have been swept up in the process of looking for and moving in to a new apartment. My roommates and I, after nearly eight months of a never-quite-gone bed bug problem, left our old place after the lease was up. We moved from Washington Heights to Hamilton Heights, a neighborhood in northwest Harlem. So far, no bugs. :)

Bed bugs have been a huge problem in NYC of late: there have been articles in the New York Times, The Economist, and by the BBC covering the epidemic. NYC's governing bodies have formed committees to address the situation. However, the problem seems to be worsened because despite such committees, the bed bug problem has no real home in city government. The obvious candidate, the Department of Health, makes the point that the bugs are not disease carriers, and hence are not a public health threat. One might argue that bugs that bite you while you sleep, producing large, itchy, reddened wheals on the face, neck, arms, legs, and torso, don't need to carry disease to be a public health threat. But really, who's to say?

Anyway, now that the bed bug/moving situation has been sorted out, my next stop is a camp in upstate New York. The camp is designed for kids that have medical needs greater than those most camps are willing to accomodate. I'll be working as a nuse/nurse practitioner student.

Back to something that is an agreed-upon public health issue in New York: it seems the ban on trans fats is working. A recent study published in the Annals of Internal Medicine has found that the ban has reduced the number of restaurants in NYC using artificial trans fats from 50% rto 2%, resulting in foods with a significantly improved fatty acid profile. The total amount of saturdated and trans fat in French fries, for example, has decreased by 50%. Also, it seems others are following NYC's lead: thriteen other jurisdictions in the USA, including California, have adopted similar bans.

atul gawande on health care costs

Great article from the New Yorker (usually not my favorite publication) about controlling health care costs. Its author, MacAurthur Fellow Atul Gawande, investigated the out of control health care costs of McAllen, Texas, in an effort to understand why health care in America costs so much. I think it's an especially important read for clinicians.

the lancet discusses global health

The British medical journal The Lancet's most recent issue features several articles of analysis of global health initiatives. This editorial (you have to register for the site to read it) serves as an interesting quick read of the broad trends discussed in this issue.

The editorial discusses the rising importance of nongovernmental, non-UN actors in global public health, such as the Gates Foundation or the World Bank. It points out this has its advantages, like more money going in to global public health, as well as its disadvantages, like a decreasing sense of financial/administrative ownership of the the health care system in the national governments of some of the countries receiving the most aid.

new health initiatives

This Saturday two public health groups, The Perinatal Network of Monroe County and the Finger Lakes Health Systems Agency, announced 13 initiatives to improve public health in northern New York.

The initiatives, which are aimed at reducing racial disparities in health, were developed by an interdisciplinary team of over 100 clergy, doctors, nurses, social workers, and insurers who which met from October to January. The initiatives include: studying the effect of maternity leave on fetal health, arranging community wide viewings of a documentary on racial health disparities, and trainings for clergy and social workers so they can teach clients how to manage chronic illnesses.

The Perinatal Network of Monroe County works to reduce racial and ethnic disparities in maternal fetal health. The Finger Lakes Health Systems Agency promotes public health by "providing a 'community table' where all stakeholders meet, conducting outreach to community groups, [and] retaining extensive data on the region's health and health care."

all i have to say about swine flu

This blog, which is about public health in New York City, has thus far said nothing about the most covered public health crisis in NYC this year: swine (H1N1) flu. This teriffic video in part explains why. The video is a quick exploration of the "death to news" ratio of swine flu and TB over the course of thirteen days. In sum: they're very different. The video's less than three minutes; click! If nothing else, the narrator makes it interesting.

NYC Health Commissioner to head CDC

President Obama announced his intention to appoint NYC's Health Commissioner the head of the CDC. Dr. Thomas R. Frieden, an infectious disease specialist, is expected to begin work in a month. This is the second time the Obama administration has pulled an official from NYC; former city health commissioner Dr. Margaret A. Hamburg is expected to be confirmed as commissioner of the Food and Drug Administration.

Dr. Frieden's efforts as commissioner are well known to most New Yorkers: no smoking in bars and restaurants, free condoms, and more accessible HIV testing. The appointment was met with enthusiasm by public health advocates in New York City: Dennis deLeon, president of the Latino Commission on AIDS in New York City, told the NY Times of Dr. Frieden: “I found he’s willing to challenge the status quo in an effort to make a difference."

new bill to try to change HIV testing practices in NYS

On April 16, 2009, a new bill was introduced into the NYS Assembly arguing for a new HIV testing MO in the state of New York. The bill would require that HIV testing "to be part of a signed general consent to medical care" signed by the patient. The bill would also require that all EDs, hospitals, and doctor's offices offer HIV tests to patients on a regular basis, with some very limited exceptions (ie, they are being treated for a life-threatening illness at the time of their visit.)

But what does it mean for the HIV test to be "part" of a "signed general consent"? In an article published April 12, The Albany Democrat and Chronicle interpreted it to mean that patients "would check a box on a general medical-consent form, which would remain in force."

Advocates say that this is still too much of a barrier. C. Virginia Fields, chief executive officer and president of the National Black Leadership Commission on AIDS, is quoted in the Democrat: "What we're saying is routine testing is when you go to a doctor and get a blood work-up, and HIV should be among those (illnesses) tested."

I'm all for lowering barriers to testing for HIV, and myself have recommended several HIV (and chlamydia and herpes and gonorrhea) tests to several patients during my NP clinicals. However, I have trouble picturing HIV being added to "routine testing" because there is no such thing. That is, when a patient turns up at a clinician's office, either perfectly healthy and there for their annual exam, or with a looong list of episodic complaints, the clinician decides what tests to order based on the patient's characteristics. Admittedly, there are some tests (complete/basal metabolic panel, complete blood count, urinalysis) that are ordered for basically everyone, but these are not for diseases as such; they test organ function and indicate disease if abnormal. All of this is to say: in the absence of true "routine tests" for disease, a bill like this one is the only way to improve testing rates via legislation. Unless of course, the legislature wants to mandate that clinicians verbally offer the test for HIV to everyone on every visit. (Come to think of it, that's not a bad idea.) In the meantime, get tested.

Finally, an editorial from the NYT advocating greater awareness of HIV in the US, and more frequent testing for the disease.

exciting step in the right direction

Woot.

The article mentions PEPFAR, which the Washington Post also did an editorial on recently.

wide county by county variation in medicaid denials

Last Thursday the Rockefeller Institute of Government published a report on the county by county variation in denials of applications for Medicaid funding of long term care. Individuals in New York are eligible for Medicaid funding for nursing home care if they make less than $8,700 per year, and if their total assets are less than $13,500, not including their home. Federal law prohibits the transfer of assets by the elderly for five years prior to applying for Medicaid nursing home benefits; obviously the intention of the law is to prevent people would could afford a nursing home on their own from filing for benefits after giving their money family member, friend, etc. so they could access it later. The report, which analyzed the state's 57 counties outside New York City, studied the rate at which Medicaid benefits are denied because of a reported asset transfer.

In the last decade, 7% of the applications for Medicaid benefits for long term care have been denied on the basis of a recent asset transfer. However, the rate at which applications are denied varies wildly from county to county. Some of the counties that deny with the most frequency are: Rockland (24.2%), Ulster (22.6%), Saratoga (14.6%), and Suffolk (14.5%). Some that deny the least are: Westchester (0.5%), Duchess (1.0%), Schenectady (1.2%), Rensselaer (1.3%), Orange (1.4%), and Erie (2.1%). The report offered no opinion as to why the variation exists, but the authors did note their suspicion that the illegal asset transfers are underdetected.

New York has one of the most generous Medicaid programs in the country; in 2006, 42% of the $18.9 billion the State spent on Medicaid went to funding long term care.

nyc anti-smoking campaign began yesterday

The NYC Department of Health and Mental Hygiene is hitting smokers where it hurts : by reminding them what smoking can do to their kids. The Department has developed two ads, based on Australia's Quit Victoria campaign, that depict how a parent's smoking habit can affect children. One of the ads features information on the side effects assoicated with secondhand smoke: asthma, pneumonia, ear infections. The campaign is called "Cigarettes are Eating You and Your Kids Alive". The second ad features a lost (and adorable) kid panicking as he looks for his parents. A voiceover features the comment: “If this is how your child feels after losing you for a minute, just imagine if they lost you for life.” Ouch.

The ads will run for about two weeks in both English and Spanish. The City Health Commissioner points out that about 400,000 smoking New Yorkers live wiht a child, and that about 8,000 New Yorkers die each year from smoking.

Hello

My first post will be just a quick introduction. I am a registered nurse pursuing a Master's degree in Nursing. My BS in Nursing was my second undergraduate degree; it was a one year accelerated program designed for students who wanted to be nurses but who already had four year degrees in other fields. My BA was in the social sciences, and one of the only two science classes I took in college was nicknamed "Sex" by the student body. (The course guide opted for the more discreet title "The Evolution of Human Nature", but it obviously fooled no one.) So transitioning into classes that actually had right and wrong answers was not easy. However, I was lucky enough to take care of my prereqs quickly, and to begin my nursing degree almost exactly a year after finishing undergad.

I was also lucky enough to get into my first choice nursing school: Columbia University. Its medical campus is centered around Columbia-Presbyterian Hospital, in the Washington Heights area of New York. A year after starting my degree at Columbia, I finished the bachelor's portion of the program and became a registered nurse. Like most people in my class, I moved on immediately to my Master's in Nursing, which, combined with passing the state's nursing boards, will qualify me to practice as a Nurse Practitioner in New York. I will complete my degree in December 2009.

In addition to nursing , I'm interested in public health, particularly in New York and particularly as it pertains to HIV. I intend for this blog to discuss all three subjects, although the ratio is to be determined. To that end, an interesting study recently came out from the New York Department of Health exploring a link between binge drinking and HIV among MSM. You can download the full study at the end of the press release.