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PNEUMONIA VACCINE INEFFECTIVE?
If you're going to test a vaccine, test it on healthy young people. That way you have a good chance of getting excellent results.
That's what they did back in the 1970s with the first test of the pneumonia vaccine. The vaccine proved to be very effective in preventing pneumonia among healthy young subjects.
But now, 30-plus years later, the elderly are the ones most likely to get a pneumonia vaccine--and many of them are in poor health.
Perhaps poor enough that their immune systems cannot respond to a vaccine.
A Swiss team analyzed more than 20 clinical trials that compared the pneumonia vaccine with control groups. These trials involved more than 100,000 subjects.
In the Canadian Medical Association Journal the Swiss team wrote: "There was little evidence of vaccine protection among elderly patients or adults with chronic illness in analyses of all trials..." And: "Pneumococcal vaccination does not appear to be effective in preventing pneumonia, even in populations for whom the vaccine is currently recommended." http://www.cmaj.ca/cgi/content/full/180/1/48
In addition, a Canadian study suggests that, for elderly people who have been hospitalized for community-acquired pneumonia (CAP), 23-valent pneumococcal polysaccharide vaccine (PPV) is ineffective in preventing another episode of pneumonia. Canadian national guidelines recommend the vaccine for all elderly people and others at increased risk for CAP.
The study, published in the Jul 1 issue of Clinical Infectious Diseases, focused on 2,950 patients, most of them elderly, who were hospitalized in Edmonton for CAP.
A third of the patients had received PPV previously or were vaccinated before they were discharged. The patients were followed for 3.8 years, during which 1,626 (55%) died or were hospitalized again for potentially vaccine-preventable infections.
After adjusting for confounding variables, the researchers found that the risk of death or reinfection was not significantly lower for the vaccinated patients than for those who were not vaccinated (hazard ratio, 0.91; 95% confidence interval, 0.79 to 1.04; P=.17). "Better pneumococcal vaccination strategies are urgently needed," the authors conclude. http://www.journals.uchicago.edu/doi/abs/10.1086/653114
Finally, among 84,170 men aged 45-69 followed from 2000 to 2007, pneumococcal vaccination did not protect against heart attack or stroke. In fact the rate of heart attack was 10.7 per 1000 person-years for those vaccinated, as opposed to 6.1 per 1000 person-years for the unvaccinated. For stroke, the rate was 5.3 per 1000 person-years for the vaccinated and 1.9 per 1000 person-years for the unvaccinated. The study was controlled for subjects' dietary habits, disease history, and lifestyle factors such as smoking and level of physical activity. (JAMA 2010;303:1699-1706).
ACUPUNCTURE FOR ULCERATIVE COLITIS
In a prospective, randomized, controlled clinical trial, 29 patients with mild to moderately active ulcerative colitis were randomly assigned to receive either traditional acupuncture and moxibustion, or sham acupuncture consisting of superficial needling at non-acupuncture points. Patients were treated in 10 sessions over a period of five weeks and followed up for 16 weeks.
Colitis Activity Index (CAI) decreased in both acupuncture andsham groups and in both cases these changes was associated with significant improvements in general well-being. Differences in efficacy between traditional acupuncture and sham acupuncture were small and significant only for CAI as the main outcome measure.
The authors conclude that both traditional and sham acupuncture seem to offer therapeutic benefit in this condition. (Acupuncture and moxibustion in the treatment of ulcerative colitis: a randomized controlled study. Scand J Gastroenterol. 2006 Sep;41(9):1056-63).
VERTEBROPLASTY NO BETTER THAN PLACEBO
Injecting cement into fractures of the spine seems to be a reasonable idea to reduce the resulting back pain. This surgical procedure has become quite popular, inasmuch as up to 25% of adults over 50 will have at least one vertebral fracture in their lifetime.
In this study, 78 participants were randomized between surgical and control groups and evaluated at one week, and one, three and six months for pain and quality of life.
At one week, the placebo group was doing better. All all other intervals and at six months post surgical procedure, there were no differences between the two groups. (A Randomized Trial of Vertebroplasty for Painful Osteoporotic Vertebral Fractures, N Engl J Med August 6, 2009;361(6):557-568)
ACUPUNCTURE IMPROVES CHRONIC KNEE PAIN
A meta-analysis has evaluated the effects of acupuncture on pain and function in patients with chronic knee pain. Combining data from five randomized controlled studies judged to have high validity (1334 patients), acupuncture was found to be superior to sham acupuncture for both pain and function. The differences were still significant at long-term follow-up. (Acupuncture treatment for chronic knee pain: a systematic review. Rheumatology. 2007 46(3):384-390).
AURICULAR ACUPUNCTURE FOR ACUTE PAIN
A randomized controlled pilot study compared the effects of standard emergency medical care to auricular acupuncture plus standard care in patients with acute pain syndromes. Eighty-seven people with a diagnosis of acute pain completed the emergency room (ER) trial.
Participants in the acupuncture group experienced a 23% reduction in pain before leaving the ER, while average pain levels in participants in the standard medical care group remained unchanged. However, both groups experienced a similar reduction in pain 24 hours after treatment in the ER. (Auricular acupuncture in the treatment of acute pain syndromes: A pilot study. Mil Med. 2006 Oct;171(10):1010-4).
AURICULAR ACUPUNCTURE REDUCES PAIN AFTER KNEE SURGERY
The authors of this study investigated the need for postoperative pain medication in 120 patients undergoing knee surgery. Participants randomly received true auricular acupuncture (Lung, Shenmen and Knee points) or a sham procedure (three non-acupuncture points on the auricular helix) on the ipsilateral ear before ambulatory knee arthroscopy.
Permanent press needles were retained for one day after surgery and post-operative pain was treated with ibuprofen. Pain intensity was similar in both groups at all time points, but those in the acupuncture group required significantly less post-operative ibuprofen than controls. (Auricular acupuncture for pain relief after ambulatory knee surgery: a randomized trial. CMAJ. 2007 Jan 16;176(2):179-83).
HOW MUCH BENEFIT FROM STATINS FOR THOSE WITHOUT CARDIOVASCULAR DISEASE?
For those without cardiovascular disease who still have risk factors, a meta analysis of 10 studies which included 70,388 participants suggested that all cause mortality was reduced from 57 per thousand for those taking statins to 51 per thousand in the control group.
This is an absolute risk reduction of 0.6%.
However, in the fashion of modern medical journals, the relative risk reduction of 12% is what receives the headlines.
The relative risk reduction of 30% in cardiovascular events, and 19% reduction in cerebrovascular events translates to almost 2 people per thousand and 1 person per thousand, respectively. Using absolute risk makes it easier to determine that 1000 people have to be treated with statins for 3 people to benefit (997 of 1000 will see no benefit for these outcomes). (Bruggs, JJ, et al. The benefits of statins in people without established cardiovascular disease, BMJ, June 30, 2009;338:b2376).
NATURAL FORMS OF MARIJUANA MAY BE BETTER FOR MENTAL HEALTH
One of the components of cannabis (CBD, cannabidiol) which is not psychoactive seems to reduce the effects of the psychoactive component, (THC, tetrahydrocannibinol) to cause symptoms normally associated with psychosis. These components usually are found together in naturally found cannabis plants, but in plants specially grown to increase the THC component, CBD is decreased.
In one human study, published in Neuropsychopharmacology (DOI:10.1038/npp.2009.184) , functional MRI scanning demonstrated that THC and CBD had opposite effects on brain function. Research to see if CBD has beneficial psychiatric effects is being pursued by the Beckley Foundation based in Oxford, UK. (New Scientist Jan 23, 2010 p 22).
20% OF OBESE CHILDREN HAVE FATTY LIVER DISEASE
Fatty liver disease was found in 14-50% of 156 five to twenty year olds, according to a report presented to the American Association of Clinical Endocrinologists. These were non diabetic children who did not have thyroid disease.
Fatty liver disease was found in twice the number of males as females.
These results, if generalized to the overweight population of the United States, promise a future of incredibly expensive and complicated endocrine, cardiovascular, and orthopedic issues that will vastly exceed the present levels of chronic disease. In 9 years, fatty liver disease is projected to exceed alcohol and hepatitis as a reason for liver transplantation.
Unfortunately, the response of professional organizations is limited to screening and “increasing awareness”. (Family Practice News May 15, 2010 p 1).
(Ed.)The medical model of disease has not provided any value in the resolution of the cultural disorder that is now fashionable to confuse with infectious disease: the “obesity epidemic”.
AURICULAR ELECTRO-ACUPUNCTURE REDUCES HISTAMINE ITCH
In a study of 32 healthy volunteers, histamine was applied to both forearms, followed five minutes later by electro-acupuncture to either the left or right ear. The extent of skin reddening on both arms was measured before and after acupuncture.
As a control procedure, subjects underwent a second bilateral histamine application and measurement four weeks later, without acupuncture. Acupuncture was found to significantly reduce (and in some instances prevent altogether) the area of itchy redness on the ipsilateral forearm only. (Effect of acupuncture on experimentally induced itch. Acta Derm Venereol. 2006;86(5):399-403).
ACUPUNCTURE EASES TMJ PAIN
A double-blind randomized controlled trial followed twenty-seven patients suffering from temporomandibular joint myofascial pain (TMJ/MP) who were assigned to receive either real acupuncture or a sham acupuncture intervention.
Real acupuncture was found to have a greater influence than sham acupuncture on clinical outcome measures of TMJ/MP and changes in the majority of measures reached a level of statistical significance. (The efficacy of acupuncture in the treatment of temporomandibular joint myofascial pain: a randomized controlled trial. J Dent. 2007 Mar;35(3):259-67).
ACUPUNCTURE STOPS GAGGING
Acupuncture at REN-24 is an effective method of controlling the gag reflex, which can prevent patients from receiving dental treatment. For this study, members of the British Dental Acupuncture Society took part in a patient audit.
Patients had two upper dental alginate impressions taken (or attempted), one before and one after acupuncture at Chengqiang REN-24.
Prior to acupuncture, none of the 37 patients was able to tolerate the procedure, however after acupuncture there was a mean improvement of 53% in measures of gagging severity at all stages of the impression taking process. 81% of patients were able to accept the impression taking after acupuncture. (The use of acupuncture in controlling the gag reflex in patients requiring an upper alginate impression: an audit. Br Dent J. 2006 Dec 9;201(11):721-5).
ACUPUNCTURE FOR ANXIETY AND PAIN DURING LITHOTRIPSY
A randomized controlled study was carried out to determine whether a combination of auricular and body acupuncture is effective as an adjunctive treatment for preprocedural anxiety and pain, in 56 patients undergoing lithotripsy (ultrasonic destruction of kidney stones).
In the acupuncture group, preprocedural auricular acupuncture was combined with intraprocedural electro-acupuncture stimulation, while in the control group both treatments were sham.
Patients in the acupuncture group were less anxious preprocedure than those in the sham group and they also used a significantly smaller amount of analgesic during the procedure than those in the sham control group. Patients in the acupuncture group also reported significantly lower pain scores on admission to the recovery room. (Acupuncture as An Adjunct for Sedation during Lithotripsy. J Altern Complement Med. 2007 Mar;13(2):241-246).
"Is Anyone Thinking?" Department
IS YOUR PHYSICIAN TEXTING WHILE DOCTORING?
Driving a car, for most people, is a fairly routine activity. Nonetheless, things can happen very rapidly, and a moment of inattention can quickly transform the routine into a horrifying disaster. Distracting oneself with texting or eating, or dialing a cell phone is a dangerous activity that may easily result in death or dismemberment.
Most people actually don’t multitask very well. In fact, focusing on one task with perfect concentration is a demanding challenge for even the mentally acute, as experienced meditators can attest. If it is clear that experienced drivers cannot function at a high level when they are at a keyboard, how much attention do we expect a physician to maintain when they are navigating their way through a series of templates, forms and pages of an electronic medical record?
Depending on the programming, most electronic medical records do not permit the open ended entering of information in the easy fashion of writing in a paper chart. To find a page where information can be entered that is not a standardized template or a coded entry may require several clicks of a mouse.
Imagine if you had to write sentences in a word processor by pulling down menus of alphabetized pronouns, adjectives, adverbs, conjunctives, verbs, and objects, highlighting them to add each word to the sentence.
How long would it take to write a paragraph?
This is about how ponderous most electronic medical records are if anything beyond the programmed entries is required. Frequently, unusual and non predictable information, elicited during the history, is the most useful in helping the doctor eliminate unlikely possibilities and focus on productive avenues of investigation.
Odd and idiosyncratic findings are often the most important part of the visit for the doctor: If this never makes it into the record, the value of the record for the patient and other professionals is severly compromised.
Of equal concern is the fact that a doctor who is typing into a screen is not going to be intellectually involved in analyzing the information presented, and pursuing the relevant questions or exam: Would we expect an attorney to do an adequate job of defense or prosecution if she had to be the court reporter also?
Questioning a patient and determining the most likely avenue of investigation, for everything more complex than the most simple disorder, is a process demanding most of a physician’s attention. Looking at a screen of necessity means the doctor won’t be noticing body langage at all, and it is more likely that verbal nuances and subtle examination findings will be ignored or never considered because they aren't seen, smelled, heard, or felt.
Don’t expect that your doctor will later have time to review and think about even the information obtained in this distracted state, or reflect on issues not considered or pursued during the visit. The moment for skillful and wise intervention may be past, as the constant press of administrative, legal, and time pressures ensures that your “problem list” will not be considered or thought about until the next visit.
And, in these days of increasing concern about cross contamination by bacteria, fungi and viruses, how many doctors are going to be washing their hands every time they sit down to or leave the mouse and the keyboard?
Physical diagnosis has already become a bit of a lost art, and this essential part of the visit has further declined with the intrusions of computers into the examination room.
I believe you should have your doctor’s full attention for the brief moments of the modern medical visit. If you wouldn’t be happy if she was on the phone with her broker or eating lunch during your visit, you should not be satisfied by a medical encounter where the doctor is playing an elaborate computer billing game to satisfy their bureaucratic overlords.
Practicing the suggested body language pictured above may assist in obtaining her attention.
GADGET OF THE MONTH
"Suitable for any age, its patented Italian design incorporates Japanese engineering and utilizes acupressure to relax and soothe problems away."
And probably much better than those tin foil hats to prevent unwanted radio waves from affecting sensitive brains.