A Country Doctor Writes:

Hypertension Hot Potato — Anatomy of the Angiotensin-Receptor Blocker Recalls | NEJM

I had not seen any numbers on the magnitude of the cancer risk in the angiotensin receptor blocker recall avalanche. A couple of days ago the New England Journal of Medicine published the number – one new case of cancer per 8000 users of maximum doses for four years:

Although not all products containing valsartan, irbesartan, or losartan that are marketed in the United States have been recalled, the scope of the exposure, the scale of the 20 recalls, and their impact on patient care are substantial (see timeline). FDA officials believe that U.S. patients have been ingesting ARBs containing carcinogenic impurities for approximately 4 years; they estimate that for every 8000 patients taking the highest dose of an affected product for the full 4 years, one new cancer above the background incidence would be expected.
— Read on http://www.nejm.org/doi/full/10.1056/NEJMp1901657

———

What we need to talk about when we talk about health – The Lancet

What is it then that we need to talk about when we talk about health? We need to talk about health as a public good, and recognise that health, like all public goods, is inseparable from politics. The reason we have libraries, public parks, a system of public education, and other such goods is because we elected leaders who made political choices to create and maintain these institutions. Public goods were once the centre of political gravity in the USA. Programmes like the New Deal and the Great Society were attempts to leverage a spirit of collective investment into a network of polices and institutions that promote wellbeing at every level of American life. In recent decades, however, the legacy of these programmes have come under attack by a political philosophy that prizes unfettered individualism above all else, even health. This philosophy, which notably informed the Reagan and Thatcher era and has now been eagerly embraced by US President Donald Trump, sees government as a largely harmful influence, and led to a campaign of roll-back and privatisation that has been good for corporations and unfriendly to the policies and institutions that promote health. In the USA, for example, the current administration has, in the name of freeing up the markets, pursued an aggressive dismantling of environmental standards, placing profits over health. It has undermined collective investment in areas like public housing, which it has sought to keep from people in need, and education, which it has worked to privatise. At nearly every turn, it has embraced an ethos of “you’re on your own”, rather than “we’re all in this together”. While the latter may sound idealistic, even utopian, it is nothing of the kind. In fact, it is the only way we can organise ourselves, as a society, if we wish to be healthy. This is especially true at a time of nationalist retrenchment, Brexit, and building walls. When we reject collective effort in favour of ever-deeper divides, we open the door to sickness and shut it to health. More…

———–

Pills or public health? – The BMJ

Once again, the Brits seem to show a more balanced view on how to treat lifestyle related chronic disease:

How best to tackle the rising tide of non-communicable disease linked to lifestyle, or, more accurately, linked to the environments in which people live? With pills or with traditional public health interventions: healthier food and cleaner air?

The push for pills is strong. As reported by the Science Media Centre, the expert response to NICE’s draft guideline on hypertension has been glowing (http://bit.ly/2IjMEgD). NICE wants to lower the threshold for starting treatment for mild hypertension. All six experts (of whom two declare industry ties and three give no statement of interests at all) welcome the draft guidance. One expert, also quoted in our own news report (doi:10.1136/bmj.l1105), suggests the guidance doesn’t go far enough.
— Read on www.bmj.com/content/365/bmj.l1791

_________

Rate of Fentanyl Positivity Among Urine Drug Test Results Positive for Cocaine or Methamphetamine. | Substance Use and Addiction | JAMA Network Open |

It is well known that heroin is often spiked with fentanyl, sometimes of great potency, causing overdose deaths. But I have also seen fentanyl in urine drug screens done on patients who admit using cocaine and are very upfront about that. Spiking cocaine with fentanyl exposes opioid naive patients to serious risks. One patient, new to our Suboxone clinic was confronted with such a test result and said, indignantly, “I guess you can’t even trust your drug dealer anymore”.

An increasing number of UDT results positive for cocaine or methamphetamine were also positive for nonprescribed fentanyl. This provides additional insight into recently reported increases in cocaine- and methamphetamine-related overdoses. Stimulant users who may be opioid naive are at a heightened risk of overdose when exposed to fentanyl. Clinicians need to be aware that patients presenting for treatment of suspected drug overdose or substance use disorder may have been exposed, knowingly or unknowingly, to multiple substances, including the combination of stimulants and opioids.
— Read on jamanetwork.com/journals/jamanetworkopen/fullarticle/2731684

Suppressing The Inward Eye Roll

The Canadian RuralMed listserv, which I was invited to join, had a comment today, inspired by my post “If You Are a Doctor, Act Like One“, Dr. Yogi Sehgal reflected on how seemingly trivial concerns can be very appropriate if you try to understand the context:

“[Dr. Duvefelt’s] post reminds of one of my little practice tips that I have learned over the years to reduce frustration in the ER.

When a patient presents to the ER or the office with a very minor complaint, and the nurse says to you, “OMG, I can’t believe they came to the ER/office with this,” followed by an eyeroll, it’s easy to get jaded or cynical. I find the simple question, “Was there something specific you were worried about?” or “What was it about this that worried you?” is the gist of the “FIFE” questions that we were taught in medical school and do so poorly except on exams. It opens up the discussion about what the real issue is and gives you a chance to educate (doctor, from the Latin “docere”, meaning “to teach”) and feel less cynical or jaded.

Real cases recently:

Patient with a tiny little scratch on their finger which probably doesn’t need a bandaid. “I have a cut I’d like to get checked out.”

You (suppressing inward eyeroll): “Was there something specific you were worried about?”

Patient: “My grandmother died of tetanus from a minor cut like this, my mother died of sepsis from blood infection from a wound like this, I’m worried I’m going to die of this too.”

You: (Aha, now I get it!) “Ok, it sounds like the issue is not your finger so much but your family history. When was your last Td? Screen for anxiety… etc.”

Teenage patient comes to ER (with Mom) with a sore foot that comes and goes for the past week, not an athlete, pain-free now: “I sometimes have a sore foot.”

You (suppressing inward eyeroll): “Was there something specific you were worried about?”

Patient and Mom: “We were worried it had something to do with her congenital hip dysplasia.”

You (Aha, now I get it!): “Ok, sounds like we need to know a bit more about the hip and mechanics of what’s going on.” (Turns out that indeed it likely was partly related to her hip in this case, and she needed to do some PT at home which she had not been doing.)”

(yogi sehgal)

——–

Sore knee? Maybe You Have a Fabella

The BBC has an interesting little piece about a small extra (sesamoid) bone that seems to be more common now than even just a hundred years ago, even though other sesamoid bones elsewhere in the body are not becoming more common.

The fabella (“little bean” in Latin) can be the cause of knee pain and perineal nerve palsy.

“Between 1918 and 2018, reports of the fabella bone’s existence in the knee increased to the extent that it is now thought to be three times as common as 100 years ago.
The scientists’ analysis showed that in 1918, fabellae were present in 11% of the world population, and by 2018, they were present in 39%.”

https://www.bbc.co.uk/news/health-47950258

The BBC originally picked this item up from a Wiley publication

“Hou (2016) recently investigated the effects of the fabella on posterolateral pain and palsy of common peroneal nerve following total knee arthroplasty. During trials, fabellae were excised from some patients but left in others. Post‐surgery, posterolateral pain and palsy of common peroneal nerve were only observed in patients who still had fabellae. Accordingly, Hou recommended removing the fabella when knee replacement surgery is performed.”

https://onlinelibrary.wiley.com/doi/full/10.1111/joa.12994

 ———–

Vaccination is Not Really Just a Personal Decision: People Don’t Understand Herd Immunity -NEJM

I may survive an infectious disease just fine, but what about vulnerable people I come in contact with? The less of it there is going around, the less risk for morbidity and mortality for everyone.

The New England Journal of Medicine editorialized about this:

Exposure to measles in the community certainly represents a danger to high-risk persons during a local outbreak; however, nosocomial transmission may pose an even greater threat and has been reported throughout the world. For example, during a measles outbreak in Shanghai in 2015, a single child with measles in a pediatric oncology clinic infected 23 other children, more than 50% of whom ended up with severe complications, and the case fatality rate was 21%.5 When the umbrella of herd immunity is compromised, such populations are highly vulnerable.
— Read on www.nejm.org/doi/full/10.1056/NEJMp1905099