onyeije’s posterous

Why Patients Who Have Had Preeclampsia Should Be Evaluated For Hypothyroidism.

This blog post was also published on preeclampsiaonline.net by Chukwuma Onyeije, M.D.

At present, the cause of preeclampsia is unknown.  However, it is clear that patients who have had preeclampsia are at risk for other cardiovascular conditions in later life.  Recently published studies now show that in addition to these concerns; patients who have had preeclampsia are also at risk for hypothyroidism later in life.

This presentation reviews why this is an important consideration for the long term health of these patients.

Diabesity Revisited - An American Epidemic.

The CDC recently provided information regarding the rates of obesity and diabetes in the United States by county.

The CDC map and accompanying article can be found here.

My first response was that rather than calling the Southeast the “Bible Belt” it should now be called the “Diabetes / Obesity Belt”

All jokes aside, the maps provided give yet another example of the massive public health problems that face our nation. For the record, at least one third of Americans are currently classified as obese

• Obesity is a major risk factor for type 2 diabetes, and it is estimated that more than 20 million Americans are currently diabetic,
• One out of three people with diabetes do not even realize that they have the disease.
  

The combination of diabetes and obesity has lead to the term “Diabesity” as a description of what many call an epidemic within the Ameican healthcare crisis. The usual suspects implicated in the diabesity epidemic include sedentary lifestyles, ubiquitous junk food, the supersizing of meal portions, and "emotional eating" are just a few.

From a public health standpoint I like the term diabesity because it makes us focus on not only esthetic aspects of obesity but rather the additional health concerns raised by the epidemic. Such a focus allows us to move from dealing with simply a largely preventable lifestyle related disease, namely obesity, and a huge and expensive health crisis, namely type 2 diabetes.

A few more sobering facts:

• Eighty per cent of type 2 diabetics are obese.
  
• Glucose metabolism are often seen with other forms of metabolic dysfunction involving lipids, uric acid, urinary albumin, clotting, inflammatory and fertility factors
  
• Additional mechanical complications such as arthritis, sleep apnea, stress incontinence, are also major health concern in this subset of the population.
  

Now, take another look at the map above. Why do you think that diabetes and obesity should be connected to geography? The CDC report suggests some answers, however, as clinicians and scientists I feel it is important that we look for underlying causes regarding why these conditions affect certain portions of the population more than others.

FURTHER READING:  Diabesity: The Obesity-Diabetes Epidemic That Threatens America--And What We Must Do to Stop It by Francine R. Kaufman, M.D.

Circulating Cell-Free DNA and Preeclampsia: Hope For Patients With HELLP?

Saxby Chamblis Responds on Net Neutrality. Kinda.

Email  
Dear Dr. Onyeije:
 
Thank you for contacting me regarding network neutrality.  I appreciate hearing from you.
The Internet is a vital communications tool for millions of Americans.  The speed and ease at which information can be retrieved over the Internet is unparalleled.  The applications and devices that can be used on the Internet enable families and friends to stay connected, businesses to accomplish their goals, and students to conduct research. 
Net neutrality is the concept of allowing Internet service providers to block or discriminate against certain content on high-speed networks.  The core disagreement regarding this concept is the question of whether the phone and cable companies that control the nation's broadband infrastructure will be able to charge for faster access to certain websites.
S. 215, the "Internet Freedom Preservation Act," was introduced during the 110thCongress and was referred to the Committee on Commerce, Science, and Transportation.  This bill would have requiredthat each broadband service provider shall enable any content, application, or service made available via the Internet to be provided on a basis that is reasonable and nondiscriminatory.  However, this legislation was not acted upon before the last session adjourned. 
 
As this debate goes forward, I will work with my colleagues to ensure fair market competition and the protection of consumers. 
 
Please contact me if I can be of assistance to you in the future.  In the meantime, if you would like to receive timely e-mail alerts regarding the latest congressional actions and my weekly e-newsletter, please sign up via my web site at: www.chambliss.senate.gov.  
 
Very truly yours,

Saxby Chambliss
 
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  Sent from Onyeije's BlackBerry Storm

What's So Important About Net Neutrality?

This may seem like something of a departure from the usual content of this blog; however, in a sense, it fits in perfectly with the ideas I have tried to express on this site and elsewhere. I have always been a strong proponent for using technology to facilitate enhanced communication and to empower individuals, patients and physicians.

It recently became clear to me that the idea of Net Neutrality is an important concept in the attempt to enhance personal freedom and unleash creativity via technology.

This video gives a good summary:

Adapted from Free Press presents, Save the Internet. ( http://www.savetheinternet.com/faq )

WHAT IS NET NEUTRALITY?

• Net Neutrality is the guiding principle that preserves the free and open Internet.

• Net Neutrality simply means no discrimination. Net Neutrality prevents Internet providers from blocking, speeding up or slowing down Web content based on its source, ownership or destination.

• The Internet has driven economic innovation, democratic participation and free speech online in large part due to the fact that it has always featured the idea of Net Neutrality.

• Net Neutrality protects the consumer's right to use any equipment, content, application or service without interference from the network provider.

• Under Net Neutrality, the network's only job is to move data -- not to choose which data to privilege with higher quality service.

• You can learn more about Net Neutrality: HERE:
  

SOUNDS GOOD. SO, WHO WOULD BE AGAINST NET NEUTRALITY?

• The nation's largest telephone and cable companies -- including AT&T, Verizon, Comcast and Time Warner Cable are AGAINST Net Neutrality. They want to be Internet gatekeepers, deciding which Web sites go fast or slow and which won't load at all.

• These large companies want to tax content providers to guarantee speedy delivery of their data. And they want to discriminate in favor of their own search engines, Internet phone services and streaming video -- while slowing down or blocking services offered by their competitors.

• Instead of a level playing field, these companies want to reserve express lanes for their own content and services -- or those of big corporations that can afford the steep tolls -- and leave the rest of us on a winding dirt road.

• The big phone and cable companies are spending hundreds of millions of dollars lobbying Congress and the Federal Communications Commission to gut Net Neutrality, putting the future of the Internet at risk.

WHY IS THIS IMPORTANT TO ME?

As a part time blogger, I have enjoyed the ability to provide content that some people find useful. Anyone who has read my blog for any length of time knows that I have strong opinions and that occasionally these opinions will change and evolve as time goes by. Many times my posts are read by only myself. At other times I can get hundreds of hits and dozens of comments in a single day. I appreciate the fact that my information is only hindered by the creativity of my ideas. I do not want my content to be given second class status at the whim of a telecomunications company. I would like to have equal access to readers around the world without hinderances beyond my control.

HOW YOU CAN HELP:

1. Sign the SavetheInternet.com petition and tell Congress to pass Net Neutrality legislation now.

2. Show your support for Internet freedom  on your Web site or blog.

3. Tell your friends about this crucial issue before it's too late.

"73 Cents" - Regina Holliday and the Search for Reason in Health Care Reform

When all is said and done; the battle for health care reform in the US is not about the Democratic party or the Republican party. It is not about a vision of big government or small government. It is about patients. It is about whether we will place value in human life or the survival of the current insurance company business models. Regina Holliday's Husband Fred was 39 years old when he died of kidney cancer. Her mural in Washington has gained international attention precisely because it challenges us to put our focus on what is truly important in the current debate.

NYT: If Health Care Is Going to Change

Sent from Onyeije's BlackBerry Storm

EHR Implementation in US Hospitals

Health economist and management consultant, Jane Sarasohn-Kahn recently blogged about the results of a report on Electronic Health Record (EHR) adoption from the Robert Wood Johnson Foundation entitled, Health Information Technology in the United States: On the Cusp of Change, 2009, 

Among the startling revelations from her post and the report are the following:

•  Fewer than 2% of American hospitals used a comprehensive electronic health record (EHR) in 2008
• Only about 1 in 5 U.S. hospitals used computerized order entry and clinical decision support. 
• Barriers to EHR adoption included inadequate capital, physician resistance, unclear ROI, maintenance costs, and problems with access to IT staff. 

Defensive Deliveries, Premature Birth and Health Care Reform

The United States finds itself in a peculiar position.  Despite the fact that we live in a prosperous and powerful nation, we lag behind many other developed nations in terms of many health related outcomes.  Perhaps nowhere is this fact more evident than in the areas of premature birth and infant mortality.  The United States now ranks 33rd in terms of infant mortality. 

We are nowhere close to the leaders in this area; countries like Singapore, Japan and Sweden; and we even have a higher infant mortality than countries like Slovenia, Cuba and New Zeland .

As I see it, the differences between our outcomes and those of other nations can be blamed on either:

• differences in patients, 
• differences in physicians or 
• differences in the nature of our health care systems.  

A recent report in the New York Times  highlights the fact that all three are involved and that in order to improve infant mortality in the United States, a much more broad-based approach needs to be adopted than those currently proposed.

The NYT article by Denise Grady details a recent report from the CDC  that high rates of premature birth are a principle reason that United States has higher infant mortality than many other countries.  

The statistical analysis between the US and Sweden is sobering and makes the nature of the problem clear:

• In Sweden, 6.3 percent of births are premature, compared with 12.4 percent in the United States
• In Sweden 2.4 babies per 1000 will die in the first year of life.  In the United States the number is 6.9 per 1000.

Is it a worthwhile goal to attempt to improve infant mortality?  

The report indicates that "If the United States could match Sweden’s prematurity rate, nearly 8,000 infant deaths would be averted each year, and the U.S. infant mortality rate would be one-third lower.”

The problem of premature birth and infant death in the US is multifactorial; and no single intervention will change the trend.

One problem mentioned in the article is the fact that the increasing use of labor induction and cesarean delivery is contributing to an increase in so called "late preterm birth" (babies born between 34 and 37 weeks) and this trend is contributing to prematurity levels as well as infant morbidity and mortality.

To be clear, there are many cases where an early delivery is necessary (and indeed life saving), but there is growing concern that some physicians are recommending early delivery where a clear medical need does not exist.  It is also clear that (in some cases) patients are requesting early deliveries which result in some of the problems previously stated.

Dr. Marian F. MacDorman, a statistician at the National Center for Health Statistics was the author of the study   and stated that  "Fifteen or 20 years ago, if a woman had high blood pressure or diabetes, she would be put in the hospital, and they would try to wait it out. It was called expectant management. Now I think there’s more of a tendency to take the baby out early if there’s any question at all.”  

Those comments point to what I feel is a critical problem in the field of perinatal medicine.  That of risk appreciation and risk tolerance.  There will always be some level of risk in the process of giving birth; however, more and more both physicians and patients are so risk averse that they are in many cases prematurely delivering a baby to avoid one risk and ending up with another risk entirely.  Defensive deliveries where a physician decides to deliver a baby early due to the fear of a lawsuit have a great deal to do with the trend in late preterm birth.  Tort reform may change the motivation of some physicians to act in this manner; however, I think that there needs to be a change in the culture of medicine and the expectations of patients to really make headway on this front.

Perhaps the larger issue that we as a society should consider is what I have called the "over-medicalized" the pregnancy.  The fact that patients are being delivered early without a clearly defined medical reason just highlights the point that adverse outcomes can result not only from the absence of an intervention, but the presence of the wrong interventions.  I'm sure many of my colleagues will disagree with me on this.  (And gee whiz, it would also appear that I am undercutting my own business model as a "high-risk" pregnancy doctor.)   

But I think we are at a point where we cannot ignore the facts. 

Home births have been shown to have outcomes that are similar to or better than hospital births IN APPROPRIATELY SELECTED PATIENTS.

Low tech interventions such as group prenatal care  that give patients a more participatory role in the birth process also have been shown to reduce premature births.

The common thread is limiting medical interventions to the subset of patients who would benefit most.

As we strive to reform health care and improve infant outcomes, a multi-pronged approach seems not only reasonable but necessary.  As physicians and patients we need to understand that more is not always better.  Sometimes more is just more; and sometimes more is worse.  

Reform your own health care: Join the ePatient Revolution.

The current interactive nature of the internet has radically changed the way in which we obtain, digest and share information. The presence of multiple, high quality, collaborative social tools has in turn lead to the concept of the “ePatient”. Such patient's are equipped, enabled, empowered, engaged, equals, emancipated and experts. The tools available on the internet and other social media sites like Facebook and Twitter allow these patient's to interact with each other and potentially to obtain better care from their physicians.

When I was an intern at Harlem hospital, the internet was in it's infancy and (I think I can safely say) few if any of the patients that I saw would have been considered ePatients. Later in my career I shared the concerns of many physicians regarding the dangers of information which patients had obtained from the internet regarding medical conditions.

Our concerns were that such patients might have easily been mislead by inaccurate, dangerous or poorly interpreted information from unreliable sources. And, while I still have concerns regarding some information on the internet; it is clear that much of the information is very well balanced and that patients who take full advantage of these resources are likely to have considerably better outcomes than those who do not take advantage of such information.

A recent conversation with a new friend on Twitter provided me with an epiphany. She said that a doctor may have to think about a rare condition for a few minutes in a year; but a patient with that same medical condition thinks about it every day. I presume this is also true for patients with chronic conditions or short term medical concerns or pregnancy complications.

More and more often I see patients who have sought out detailed information online before they speak to me in a clinical setting. This type of engagement from newly empowered patients in many cases sets the stage for a much more in depth and comprehensive conversation and is greatly appreciated.

As we debate reforms in the health care system in the United States, it is clear that regardless of what happens in the near future, there are tangible things each of us can do to improve the quality of our own health care.

Recently, Dr. Val Jones of Get Better Health spoke on ABC about what is being called the ePatient revolution. A link to the video as well as links to popular sites for patient empowerment can be found below:

RESOURCES:

Med Help

Pill Box (beta)

Google Health

Patients Like me

ePatients.net

Society for Participatory Medicine.

It will be interesting to see if other medical professionals will embrace the type of participatory model being espoused by ePatients. It will also be important to make sure that communities which have traditionally lagged behind in measures of health will encounter a digital divide due to lack of access to the types of technology that makes the aforementioned types of collaboration possible.