Dr. Buttery's Public Health BLOG

From this week's Lancet -Infectious Diseases is a paper [Volume 5, Issue 12 , December 2005, Page 733] on the results of the WHO intiative to reduce measles incidence. One of the few WHO programs to exceed its target. The objective was a 50% reduction in new measles cases by 2005, the result is a 60% reduction. Again, immunization shows itself to be the most effective of prevention tools. One caveat; this and other succesful disease intervention program must ensure that all these children, whose lives are saved, have the resources to grow into productive adults.

Posted by at 12:27 PM | Permalink | Comments (0)

For more than 2o years I have been reading research that shows that patients are likely to follow advice about prevention if their family doctor provides it. Yet from the Children's Hospital in Pittsburg: Few Physicians Discuss Obesity With Families in Outpatient Setting, Children’s Hospital of Pittsburgh Researcher Finds.
In 1995, physicians treating children in the outpatient setting offered obesity-related counseling (diet/nutrition, exercise or weight management counseling) only 4 percent of the time. That rate rose to 15 percent in 2002, according to research led by Goutham Rao, MD, clinical director of the Weight Management and Wellness Center at Children’s. We need to encourage our peers to do better.

Posted by at 10:25 AM | Permalink | Comments (0)

This graphic from the NEJM today, about changing death rates, is worth looking at, then read the article about chronic disease in less developed countries. As the editors of the NEJM note, this is one of the truly preventable diseases - Don't Smoke!

Posted by at 12:12 PM | Permalink | Comments (2)

What can we learn from our veterinary counterparts? An important discussion in today's BMJ between veterinarians and physicians on comparability & differences in ethics. The ethical problems facing doctors and vets obviously differ in some ways. A veterinary surgeon, for example, can decide when a treatment is no longer valuable and opt for euthanasia. This course is not open to doctors. A shared issue was that of consent. Humans can give consent to invasive treatment near the end of their lives, but what about a sick old pet whose owner wants it kept alive even though it might be better off dead? Are there parallels with a doctor who is faced with an incapacitated patient?

Posted by at 11:41 AM | Permalink | Comments (0)

The current issue of the BMJ focuses on human health care and potential zoonoses. This issue is put together jointly by Physicians and Veterinarians. It is free of charge, on-line, to all visitors for a fascinating set of topics. As the Editors state: "The threat of an influenza pandemic in humans and the deaths of millions of birds around the world brings the link between human and animal health sharply into focus. Now is a good time to consider the wider connections between animal and human health and to think about how the medical and veterinary professions might work more closely together for the benefit of patients of all species. This joint issue of the BMJ and the Veterinary Record is an attempt to do that."

Posted by at 11:09 AM | Permalink | Comments (0)

Today a report from the NIAID states that animal flu could lead to a pandemic in the US! They are concerned about swine flu. Are there no epidemiologists at NIAID? Didn't they go back and look at the non event from Fort Devons about 'Swine Flu' in the early 1980s when a sudden rush to immunize all adults against a pandemic caused more side affects (Guillain-Barre syndrome) than the 'flu'. At the time, Don Merchant (Chair of Microbiology at EVMS) and I performed a sample survey of the bloods of abbatoir workers in the SE Virginia Hog Industry. We found that nearly all the abbattoir workers had antibodies against swine flu. None of them remembered any significant respiratory diseases. We told the National Committee that we did not believe this was a hazard. Our prognostication was correct.

Posted by at 10:50 AM | Permalink | Comments (0)

Yesterday I suggested that End of Life care should be a public health issue. Here is one at the other end of life. "Bridging the Gaps Between Race and Genetics" is an editorial in December's AJPH that should be read by everyone in Public Health. As the writer states "Advances in the field of genetics have vast potential to revolutionize the science of medicine and the prevention of disease. However, the role of genes in the complex relationship between race and health remains hotly debated."

Posted by at 10:58 AM | Permalink | Comments (0)

In today's JAMA is a perspective article "Target Heart Disease From Birth" which recommends that all mothes start concentrating on protective dietary standards at birth to prevent heart disease later. The article focuses on the changing culture of food preparation (if any) in the home.

Posted by at 10:44 AM | Permalink | Comments (0)

From JAMA this week an abstract from Health Affairs on the penetration of Electronic Health Records into group practices show that "Only 14.1% of US medical group practices use an electronic health record (EHR) system and fewer still—11.5%—have fully implemented such a system, according to findings from a study of more than 3300 medical group practices. The Agency for Healthcare Research and Quality–funded study was conducted by the Medical Group Management Association Center for Research and the University of Minnesota School of Public Health (Gans et al. Health Aff (Millwood). 2005;24:1323-1333)."
There is a long way to go to meet the federal recommendtions.

Posted by at 5:31 PM | Permalink | Comments (0)

In a new book Cornell's Dr. Joseph Fins helps clinicians, patients, and family members make the transition. Over the last 15 years, palliative care has come into its own, with more hospices and specialty-trained physicians than ever before; yet, outside the specialty, there is still a considerable lack of understanding by medical practitioners about end-of-life care and ways to help patients make this often tricky transition. Formulating goals takes the form of advance care planning — including a living will, which outlines treatment choices; and advance directives that designate a health-care proxy and guidelines for a DNR (do-not-resuscitate) order.
This is a significant health care issue, a primary prevention issue and a should be a population based issue.

Posted by at 11:04 AM | Permalink | Comments (0)

This research, from the University of Rochester Medical Center, with more evidence about the deleterious effects of ingested lead, still fails to focus on the most effective way to prevent lead poisoning - safe housing. With leaded gasoline and leaded paint banned, with safer lead smelters the main cause of childhood lead poisoning is of from older homes. The vast majority of these homes are owned by slum landlords. A simple rental occupancy code that prohibits the rental of any dwelling untreated for presence of lead would solve most of the lead poisoning of children. yet we keep waiting until a child's blood lead level is high, then treat them and send them back to the same environment.

Posted by at 10:57 AM | Permalink | Comments (0)

Why can't nutritonisst understand how screwy their label of ' a serving ' is. One person's serving is anther person's idea of a bite. This study Just How Much Is a Serving of Dip? from the University of Pennsylvania is just in time for Thanksgiving. It should be required reading for all nutritionists and those who wish to give advice about diet.

Posted by at 10:29 AM | Permalink | Comments (0)

See today's report in the Lancet on "How Vioxx is changing US drug regulation".
at the core of the statement is "Vioxx's fallout goes well beyond Merck and its ledgers. Manufacturers facing mounting political pressure have now agreed to scale back advertising—an activity once staunchly defended by the industry. Meanwhile, the US Food and Drug Administration (FDA) has taken what some see as a defensive posture designed to avoid another safety debacle."
Maybe it is time for public health and clinical medicine to band together to push for a total ban on prescription drug advertising.

Posted by at 10:58 AM | Permalink | Comments (0)

A recent report by the London School of Economics and Political Science, funded by the Wellcome Trust, describes the background and current activity of Public Private Partnereships (PPPs). The new landscape of neglected disease drug development defines a PPP as “public health driven not-for-profit organisations that drive neglected disease drug development in conjunction with industry groups”. When you download the pdf go to page 63 for the summary. A fascinating approach to improving public health for developing countries, also applicable to disadvantaged groups..

Posted by at 10:42 AM | Permalink | Comments (0)

When Marc Lalonde published the "Health Field Effect" for Canada's Ministry of Health in 1975 he discussed how most disease was related to our environment, including our behaviors. In an article published in Lancet today the authors state that "advances in cancer treatment have not been as effective as those for other chronic diseases; effective screening methods are available for only a few cancers. Primary prevention through lifestyle and environmental interventions remains the main way to reduce the burden of cancers." Also they state that "Smoking, alcohol use, and low fruit and vegetable intake were the leading risk factors for death from cancer worldwide and in low-and-middle-income countries. In high-income countries, smoking, alcohol use, and overweight and obesity were the most important causes of cancer. Sexual transmission of human papilloma virus is a leading risk factor for cervical cancer in women in low-and-middle-income countries."
Clearly we have to improve our counseling and behavioral modification methods without becoming Orwell's Ministry of Health Police.

Posted by at 12:51 PM | Permalink | Comments (0)

From the RWJF news release today "Medicare pays some California hospitals four times more than others to care for patients with similar chronic illnesses, with no gain in quality or patient satisfaction, according to a study by the Center for the Evaluative Clinical Sciences at Dartmouth Medical School.

The ground-breaking study, released today by the California HealthCare Foundation, looks at the performance of individual California hospitals in managing seriously ill patients over a five-year period. The findings, along with a comparison of data from hospitals in five regions in California—Sacramento, San Francisco, Los Angeles, Orange County, and San Diego—also were published today in a Web Exclusive edition of the journal Health Affairs. Concurrently with the release of the Health Affairs article, the Dartmouth Atlas of Health Care project is publishing performance measures for California hospitals on its Web site."

Posted by at 9:42 AM | Permalink | Comments (0)

From the Human Fertilisation and Embryology Authority in the UK comes this intriguing question about Primary Prevention.
"Should we be allowed to test at conception for conditions such as Alzheimer's?"
A public debate on how far doctors and scientists should be allowed to go with embryo-testing techniques is being launched today by the UK fertility regulator, the Human Fertilisation and Embryology Authority (HFEA). The debate will both focus on current technologies – such as the ability to screen for breast cancer genes – and possible future developments, such as the potential to screen for inherited forms of Alzheimer’s disease.

The HFEA is launching the debate with a discussion paper Choices & boundaries - which looks at key questions raised by the embryo testing technique known as preimplantation genetic diagnosis (PGD). People are being asked give their views on where they feel the boundaries should lie on which conditions PGD can be used to test for.

Posted by at 12:59 PM | Permalink | Comments (0)

An article in the Lancet this week suggests that Waist:Hip ratio is a better indicator of likelihood of heart attack than BMI. The study leading to tbis conclusion involved examination of 27,000 people from 52 countries.

Posted by at 12:50 PM | Permalink | Comments (0)

This news from Brigham and Women's Hospital "Kids Too Often Prescribed Antibiotics for Sore Throat"
Each year, millions of children visit their family physician or pediatrician seeking treatment for sore throats. While a sore throat could indicate many common illnesses, physicians are often most concerned about bacterial infections that warrant antibiotic treatments. The most common cause of sore throat for which antibiotics are indicated is group A streptococcal pharyngitis, or “strep throat.” Many leading health organizations such as the Centers for Disease Control and Prevention and the American Academy of Pediatrics indicate that a common streptococcal or “strep” test be performed prior to prescribing recommended antibiotics.
I have heard this for at least 40 years. We can't we change physician behavior? Is it so easy to prescribe antiobiotics that we do not think of the dangers? Why are doctor's being reimbursed for antibiotic treatment without evidence of lab tests? This is a system failure, as seen in the IOM "To err is human'?
See a similar news story from Washington University in St. Louis.
and in JAMA a related article from the Salt Lake City Health Care System on using Clinical Decision Support Systems to reduce inappropriate antimicrobial prescribing.

Posted by at 12:30 PM | Permalink | Comments (0)

This note from Dr. Garg should make all of us think about the best way to vaccinate the public. It is poor public relations and probably poor economics if patients cannot obtain timely flu vaccine from their primary care physician. Dr Garg writes:
"Unfortunately the doctors offices lose out - they get the vaccines last after all the big conglomerates, warehouses, drug stores and grocery stores get it. And furthermore, as we doctors receive our supply, finally in mid-November or late november, a lot of missed opportunities for vaccination pass by. I did receive my doses of flu vaccine I ordered finally this week which should be enough at least for my highest risk patients. However, this past month I had a LOT of lost opportunities for immunization, because some of the oldest and sickest patients who see me on a regular basis were in the office and wanted to get flu vaccine. They were surprised to hear that the vaccine didn't get delivered to their doctor, but the local grocery stores had it."
What should the CDC/CMS role be in ensuring availability of flu vaccine to primary care doctors? Surely the doctor's office should receive vaccine beforr the corner grocery stores.

Posted by at 12:16 PM | Permalink | Comments (4)

Every thirty seconds a lower limb is lost to diabetes somewhere in the world
at least 50% of all diabetic leg amputations can be prevented

The theme for World Diabetes Day 2005 is Diabetes and Foot Care. World Diabetes Day is held each year on 14 November. It draws attention to the millions of lives affected by diabetic foot complications and the simple and low cost ways to avoid leg amputations.

The slogan for this year is Put Feet First: Prevent Amputations.

Posted by at 12:02 PM | Permalink | Comments (0)

From the school of medicine, Otago University in New Zealand in a letter to the editor of the BMJ, Nick Wilson notes "Having only a partial ban on smoking in public places is seriously inadequate in terms of protecting the public health from secondhand smoke.1 New Zealand introduced a complete ban on smoking in restaurants and bars in December 2004. This ban has been well accepted by the public, with a clear majority showing support five months after its introduction (69% in April 2005).

Compliance with the law seems to be high, 97%,3 and legal action by health authorities against publicans defying the law has been rare. Trends in national tobacco sales data since the law are not yet available, but the legislation was associated with a significant increase in the number of calls to the national Quitline.4 A significant increase in the dispensing of subsidised nicotine replacement treatment vouchers has also occurred. "

Posted by at 11:56 AM | Permalink | Comments (0)

Urban Britain is a recipe for heart disease
This research from the University of Manchester in the UK shows that emigration to the UK, like emigration to the US, may lead to an increased risk of chronic diseases.

Posted by at 12:45 PM | Permalink | Comments (0)

From the Howard Hughes Medical Institute comes this story that tells us whyI throw up when I smell, or even read, the word "Tripes", or when President George Bush sees Broccoli.
Worms Know Bad Food When They Smell It
For most people, a whiff of food that made them sick in the past is enough to trigger a wave of nausea - and to prevent them from eating that food again. It's a response that's instantaneous, involuntary, and so fundamental to basic biology that it occurs in a broad range of species. Even worms, researchers have now shown, quickly learn to avoid smells associated with foods that have made them ill.

Posted by at 12:30 PM | Permalink | Comments (0)

A fascinating report in the Lancet today on findings in Hungary about a way to produce a split virus vaccine in less than 2 months, rather than the expected 6 months. The vaccine does not rely on chicken eggs for manufacture, which speeds production considerably. How much of the "nos" are due to good science or from drug company fears of being scooped by a "minor" player.

Posted by at 11:59 AM | Permalink | Comments (0)

An excellent review article in Science on the importance of the federal flu initiative which should be read by all public health professionals.

Posted by at 11:39 AM | Permalink | Comments (0)

With concern about Avian Flu, an increasing incidence of multidrug resistant TB and newly emerging infections there is an concern about the need to establish quarantines. The AMA has provided guidelines that include:

use valid scientific methods to assess public health risks;

avoid arbitrary application of quarantine and isolation to particular socioeconomic, racial or ethnic groups;

advocate for access to public health services for timely detection of risks and implementation of quarantine and isolation;

educate patients about the importance of their compliance with public health measures;

support mandatory quarantine and isolation for patients who fail to comply with such measures.

Posted by at 11:22 AM | Permalink | Comments (0)

I am concerned that our zeal to push health promotion may turn us into a "Public Health Police', at which time we will loose all public credibility, as the APHA has and as the ACPM is moving towards with its publications on health proomotion that seem to have little balance, a problem for many academics. Look at this excellent discussion from the King's Fund in the UK - "Nanny or Steward?"

Posted by at 11:14 AM | Permalink | Comments (0)

The graph below, from today's MMWR shows that over the years, despite all our efforts, the never smoking rate for yougf adults has only increased 4%. While this is slow we need to keep plugging away.

Posted by at 3:13 PM | Permalink | Comments (1)

A Columbia-Led Study of Nearly 7,000 Women Overcomes Traditional Barriers to More Expensive, Cumbersome Pap Tests for Highly Preventable & Treatable Cancer
The two screen-and-treat methods, human papillomavirus (HPV) DNA testing and visual inspection with acetic acid (VIA), followed by treatment using cryotherapy for all eligible women with positive test results, were found to perform as well or better than traditional cytology-based screening (Pap smear) for identifying high-grade cervical cancer precursor lesions. Cryotherapy – freezing the cervix – is a relatively low-technology treatment method that has been shown to be highly efficacious with minimal morbidity. This study was the first time these methods were tested for efficacy in reducing the prevalence of cervical cancer precursor lesions.

Posted by at 1:34 PM | Permalink | Comments (0)

I thought we all 'knew" this but a report in the November ACOG journal shows that "Smoking during pregnancy increases the risk of preterm birth, placental abruption, placenta previa, and low birth weight. Infants born with low birth weight (less than 5 ½ lbs) are at high risk for illnesses, even into adulthood. Other risk factors for low birth weight include maternal body mass index, the number of previous births, and preterm birth.

Researchers studied data on 160 women in Vermont who were enrolled in a university-based outpatient research clinic for smoking cessation and relapse prevention during pregnancy and postpartum between June 2001 and February 2003. After controlling for other known risk factors for low birth weight, including preterm birth, they found that the number of cigarettes a woman smoked in the third trimester directly correlated with newborn birth weight. For every cigarette smoked on a daily basis in the third trimester, there was a corresponding estimated reduction of 27 grams in newborn birth weight. "

Posted by at 1:30 PM | Permalink | Comments (0)

From the Oct 22 edition of thw Lancet a study from Yurkey suggests that "contrary to the prevailing theory that BCG vaccination protects only against tuberculosis disease, our results suggest that the vaccine also protects against tuberculosis infection. This finding has important implications for our understanding of the biology of tuberculosis infection and development of improved tuberculosis vaccines."

Posted by at 3:09 PM | Permalink | Comments (0)

Are boys really more hyperactive than girls? Do you believe this data? Do you even think this condition is a real condition, a politically correct diagnosis, on attempt to sell unecessary medication and treatments rather than resorting to better parental oversight?

Posted by at 12:57 PM | Permalink | Comments (0)

An advisory committee to the Centers for Disease Control and Prevention (CDC) has recommended that all children in the United States receive hepatitis A vaccine. The previous recommendation of the Advisory Committee on Immunization Practices (ACIP) in 1999, called for vaccinations in states with the highest rates of hepatitis A.
The ACIP recommendation is for children to receive the first dose of a two dose
series of hepatitis A vaccine between 1 and 2 years of age and that the vaccine
be integrated into the routine childhood vaccination schedule.

Posted by at 12:26 PM | Permalink | Comments (0)

In a surprising outcome, investigators at Wake Forest University Baptist Medical Center found that diabetic black men have dramatically lower amounts of atherosclerosis, or hardening of the arteries, than diabetic white men.

Barry I. Freedman, M.D., and colleagues report in the December issue (Volume 48, No. 12) of Diabetologia that African-American men had significantly lower levels of calcified atherosclerotic plaque in the coronary (heart) arteries and the carotid arteries in the neck that supply blood to the brain. The report was published on line today (Nov. 1, 2005.)

“This striking result was observed despite black subjects having higher levels of conventional risk factors for heart disease,” said Freedman. “These risk factors would normally be expected to promote coronary artery disease in the black participants.”

Posted by at 12:13 PM | Permalink | Comments (0)

Joslin Experts Offer Tips For Living Well With Diabetes
Experts at Joslin Diabetes Center say getting involved with your own care, and knowing how well your treatment plan is working, is crucial to diabetes management. “Regularly monitoring your blood glucose, cholesterol and blood pressure — and keeping them at or below target levels — along with periodic eye and foot exams and kidney function tests help to prevent or slow diabetes complications,” says Martin J. Abrahamson, M.D., Medical Director at Joslin Diabetes Center in Boston and Associate Professor of Medicine at Harvard Medical School.

Posted by at 12:10 PM | Permalink | Comments (0)

A new study led by Columbia University Medical Center researchers demonstrates the safety and efficacy of two low-tech diagnostic tools to significantly reduce the prevalence of cervical cancer precursor lesions. Cervical cancer is the leading cause of cancer-related death in women in many developing countries. Designed as rapid screen-and-treat methods that could be done the same day, the protocols could finally make prevention of cervical cancer a viable option for all women in any setting around the world.

The two screen-and-treat methods, human papillomavirus (HPV) DNA testing and visual inspection with acetic acid (VIA), followed by treatment using cryotherapy for all eligible women with positive test results, were found to perform as well or better than traditional cytology-based screening (Pap smear) for identifying high-grade cervical cancer precursor lesions. Cryotherapy – freezing the cervix – is a relatively low-technology treatment method that has been shown to be highly efficacious with minimal morbidity. This study was the first time these methods were tested for efficacy in reducing the prevalence of cervical cancer precursor lesions

Posted by at 12:07 PM | Permalink | Comments (0)

From ACOG, viewable on line a report that reducing smoking, even late in pregnancy, improves birth weight is important validation of public health education of our patients.

Posted by at 12:04 PM | Permalink | Comments (0)

Lack of clarity may by why many public health messages receive little attention. According to new research from the Princeton University in New Jersey Writers who use long words needlessly and choose complicated font styles are seen as less intelligent than those who stick with basic vocabulary and plain text, according to new research from the Princeton University in New Jersey, to be published in the next edition of Applied Cognitive Psychology.

Posted by at 9:42 AM | Permalink | Comments (1422)