Posts Tagged With: family medicine

How well does the Wells PE rule exclude PE?


Schouten HJ, Geersing GJ, Oudega R, et al. Accuracy of the Wells Clinical Prediction Rule for Pulmonary Embolism in Older Ambulatory Adults. J Am Geriatr Soc. 2014 Nov 3. doi: 10.1111/jgs.13080. (Original) PMID: 25366538

OBJECTIVES: To determine whether the Wells clinical prediction rule for pulmonary embolism (PE), which produces a point score based on clinical features and the likelihood of diagnoses other than PE, combined with normal D-dimer testing can be used to exclude PE in older unhospitalized adults.

DESIGN: Prospective cohort study.    SETTING: Primary care and nursing homes.

PARTICIPANTS: Adults >/=60 clinically suspected of having a PE (N = 294, mean age 76, 44% residing in nursing home).

MEASUREMENTS: The presence of PE was confirmed using a composite reference standard including computed tomography and 3-month follow-up. The proportion of individuals with an unlikely risk of PE was calculated according to the Wells rule (

RESULTS: Pulmonary embolism occurred in 83 participants (28%). Eighty-five participants had an unlikely risk according to the Wells rule and a normal D-dimer test (efficiency 29%), five of whom experienced a nonfatal PE during 3 months of follow-up (failure rate = 5.9%, 95% confidence interval (CI) = 2.5-13%). According to a refitted diagnostic strategy for older adults, 69 had a low risk of PE (24%), two of whom had PE (failure rate = 2.9%, 95% CI = 0.8-10%).

CONCLUSION: The use of the well-known and widely used Wells rule (original or refitted) does not guarantee safe exclusion of PE in older unhospitalized adults with suspected PE. This may lead to discussion among professionals as to whether the original or revised Wells rule is useful for elderly outpatients.

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Engage With Grace

From Paul Levy’s Not Running a Hospital blog

@engagewithgrace #blogrally12 Once again, a group of us (including Matthew Holt, Alexandra Drane and our friends) are launching the Engage With Grace blog rally to coincide with Thanksgiving weekend. As in previous years, we’re suggesting that people who want to join the rally simply post the attached “ready made” blog content starting tonight, November 21, and leave it up through the entire weekend (consider it a much-deserved break from blogging for a couple days).

One of our favorite things we ever heard Steve Jobs say is… ‘If you live each day as if it was your last, someday you’ll most certainly be right.’

We love it for three reasons:
1)      It reminds all of us that living with intention is one of the most important things we can do.
2)      It reminds all of us that one day will be our last.
3)      It’s a great example of how Steve Jobs just made most things (even things about death – even things he was quoting) sound better.
Most of us do pretty well with the living with intention part – but the dying thing? Not so much.
And maybe that doesn’t bother us so much as individuals because heck, we’re not going to die anyway!! That’s one of those things that happens to other people….
Then one day it does – happen to someone else.  But it’s someone that we love.  And everything about our perspective on end of life changes.
If you haven’t personally had the experience of seeing or helping a loved one navigate the incredible complexities of terminal illness, then just ask someone who has.  Chances are nearly 3 out of 4 of those stories will be bad ones – involving actions and decisions that were at odds with that person’s values.  And the worst part about it? Most of this mess is unintentional – no one is deliberately trying to make anyone else suffer – it’s just that few of us are taking the time to figure out our own preferences for what we’d like when our time is near, making sure those preferences are known, and appointing someone to advocate on our behalf.
Goodness, you might be wondering, just what are we getting at and why are we keeping you from stretching out on the couch preparing your belly for onslaught?
Thanksgiving is a time for gathering, for communing, and for thinking hard together with friends and family about the things that matter.  Here’s the crazy thing – in the wake of one of the most intense political seasons in recent history, one of the safest topics to debate around the table this year might just be that one last taboo: end of life planning. And you know what? It’s also one of the most important.
Here’s one debate nobody wants to have – deciding on behalf of a loved one how to handle tough decisions at the end of their life. And there is no greater gift you can give your loved ones than saving them from that agony.  So let’s take that off the table right now, this weekend.  Know what you want at the end of your life; know the preferences of your loved ones.    Print out this one slidewith just these five questions on it.
Have the conversation with your family.  Now.  Not a year from now, not when you or a loved one are diagnosed with something, not at the bedside of a mother or a father or a sibling or a life-long partner…but NOW.  Have it this Thanksgiving when you are gathered together as a family, with your loved ones.  Why? Because now is when it matters. This is the conversation to have when you don’t need to have it.  And, believe it or not, when it’s a hypothetical conversation – you might even find it fascinating.  We find sharing almost everything else about ourselves fascinating – why not this, too?   And then, one day, when the real stuff happens?  You’ll be ready.
Doing end of life better is important for all of us.  And the good news is that for all the squeamishness we think people have around this issue, the tide is changing, and more and more people are realizing that as a country dedicated to living with great intention – we need to apply that same sense of purpose and honor to how we die.
One day, Rosa Parks refused to move her seat on a bus in Montgomery County, Alabama.  Others had before. Why was this day different?  Because her story tapped into a million other stories that together sparked a revolution that changed the course of history.
Each of us has a story – it has a beginning, a middle, and an end. We work so hard to design a beautiful life – spend the time to design a beautiful end, too.  Know the answers to just these five questions for yourself, and for your loved ones.  Commit to advocating for each other.  Then pass it on.  Let’s start a revolution.
Engage with Grace.
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But Doc, I’ll just gain weight if I quit smoking

I saw this in the British Medical Journal.  My patients know they shouldn’t smoke, but fear of weight gain holds many back.  These are some useful statistics to share with them.

The meta analysis by Aubin et al ( ) showed:

•    Average weight gain was 8-11 pounds 1 year after quitting
•    13% of people gained more than 22 pounds  
•    16% lost some weight
•    Method of quitting didn’t affect weight.

Commentators noted 

  • Study participants may have enrolled because they have less willpower than average; so people who can quit smoking on their own may be less likely to overeat and gain weight.
  • Cohort studies have shown short-term weight gain among quitters but long-term trends similar to those of non-smokers
  • Being a bit overweight doesn’t kill you, but smoking may.

An accompanying editorial can be found here: Quitting smoking and gaining weight: the odd couple | BMJ.

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How Healthy Is Houston? Health of Houston Survey 2011

Some of the results are not surprising, but others contradict our assumptions:

  • Houston’s rate of mental illness is twice the national average (twice that of Los Angeles County)
  • Almost half of Houstonians reported difficulty purchasing enough food or paying their mortgages
  • 34% of adults under 65 are uninsured
  • 56% of Hispanic residents are uninsured compared to 14% of whites
  • When undocumented residents are excluded, 46% of Hispanics are uninsured
  • Half of adults have no dental insurance (explains why family doctors see so many dental complaints)
  • 32% of adults are obese
  • 3% were frightened for their safety

A Q&A with Dr. Stephen Linder

Written by: Anissa Anderson Orr  |  Updated: August 28, 2012

As a professor of public health, Dr. Stephen Linder helps inform Houstonians about ways to prevent disease and stay healthy. But diagnosing each community’s health care needs poses a challenge. Studies on the health of Houston-area residents—a diverse population of nearly 6 million people—don’t always show the whole picture.

“Doing a population-based survey was the missing piece in the mosaic of data that Houston needs,” explains Linder, associate director of the Institute for Health Policy at The University of Texas School of Public Health. “We needed a better sense of what the total need for health services is on a community-wide basis, rather than keeping a tally of those who actually get services.”

To fill in the blanks, Linder and his colleagues developed the 2010 Health of Houston Survey, released to the public, and on their website, in November of 2011. With information from more than 5,000 households, and covering 28 areas within Harris County, the population study is the first of its kind to report the health of Houstonians by neighborhood (click here to see where your neighborhood stands).

So how healthy is Houston really? We definitely have some room to improve, Linder says. An estimated 20 percent of Houstonians reported they are in poor or fair health—twice the national average. Lack of health insurance, health care access and increased risk for psychological distress were big problems in some neighborhoods. HealthLeader recently sat down with Linder and asked him what the study results say about Houston.
HealthLeader: Houston has always had a reputation, fair or not, for being unhealthy. But did you expect so many of your study respondents to say they were in fair or poor health?

Dr. Stephen Linder: It was a surprise. Our sense was that the interesting feature of the study would be the geographic disparities—some neighborhoods having more problems than others—and not the deviation from national averages. We thought our local rates would be close to the national average, or at least within 10 percent. Not twice the national rate for certain adverse health conditions.

HL:What else was surprising?

SL: We found that Houston had twice the national rate for risk of psychiatric illness. Not only that, the rate for women was twice as high as for men. We compared it to Los Angeles County, which has similar demographics as Houston. L.A. County had lower than the national rate for the risk of psychiatric illness, and thus less than half of the average in Houston, and it reversed the gender disparity. Men were doing a little better than women were in L.A. County, but we have no idea why. When we repeat the survey in 2013, we are going to ask a more extensive battery of questions about mental health to see if we can sort out the source of that gender disparity.

HL:Were you surprised by the disparities you found in insurance coverage among Houstonians?

SL: We knew the percentage of people who were uninsured was high in Houston, so we expected a high uninsured rate. But, we found that the overall rate of people who were uninsured was 34 percent in Harris County. That’s not only dramatically higher than the national rate; it is also higher than the L.A. County rate, which is 10 points lower than ours. The real surprise, however, was the disparities across population groups. The largest difference in insurance coverage was between whites and Hispanics. About 14 percent of whites were uninsured, but 56 percent of Hispanics were uninsured. If we exclude those who were undocumented, the number dropped to 46 percent. Asians, African-Americans and whites all had better than the area average in insurance coverage.

HL:What did survey respondents think was the biggest problem facing their neighborhood?

SL: Crime wasn’t at the top of the list. Instead, they named stray dogs and cats as their biggest concern. That wasn’t what we expected. It was worst on the east side of Houston. Strays can be a big problem for neighborhoods, because they increase the risk of animal bites and rabies if you have a lot of animals that have not been inoculated. Usually children are at the highest risk for being bitten.

HL:Does Houston rank the best in anything?

SL: We have done well in reducing smoking rates. Our current smoking rate is lower than the national average. Unfortunately, it is not as low as L.A. County. About 17 percent of the Houston population smokes. Nationally, the average is a little over 21 percent, and L.A. County was 13 percent. So they are doing something right in L.A., but it is worth noting that we are doing better than most places. Another area we did well in was breastfeeding. We have already exceeded the U.S. Department of Health and Human Services’ Healthy People 2020 targets for initiation of breastfeeding. For sustaining breastfeeding up to six months, which is what the Centers for Disease Control recommends, we are below the 2020 targets, but we are doing better than the state is, and better than the national average.

HL:What will the 2013 study look like?

SL: We want to include more questions on mental and dental health and investigate some of the anomalies in the results, such as why the rate of uninsured is so high among Hispanics, and why women are at such higher risk for mental illness. We will start collecting data in 2013, and plan to release the study in the fall of 2014.

HL:What should Houston focus on to improve our citizens’ health?

SL: We need to attend to geographic disparities in health, and to do so in more of an integrated fashion. We should concentrate on those hot spots of need in a way that responds to the full spectrum of needs, as opposed to singling out a disease or condition, like heart disease or diabetes.

There also are inequalities in the burden of illness and access that make some populations more vulnerable to disease. Now we have a way to measure these disparities with the indicators in our survey. Given the scale of the survey and the variety of indicators we have we can understand the problem of health disparities more fully and work toward solutions.
For more information on the Health of Houston survey, visit the UTHealth newsroom.

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Should Lack Of Exercise Be Considered A Medical Condition?

I recently returned from a trip to Portland and Seattle.  The legions of cyclists, runners, and walkers I saw in these two cities inspired me.  Bike lanes and beautiful waterfront walking paths abounded.  A Portland city bus even stopped to let me cross the street.  That would never happen in Houston.

The idea that activity is good is not news to any of us.  But if the solution is so obvious, why aren’t we all moving?

This National Public Radio story from last week attempts to answer this question.

Doctors need to prescribe exercise to patients who don’t get enough exercise, a Mayo Clinic expert says.

“You’ve got a bad case of deconditioning,” the doctor says.

Actually, it would be the rare doctor who would say that to anyone. And though it might sound like something to do with hair, in fact, deconditioning is a familiar and more profound problem: the decidedly unnatural state of being physically inactive.

At some point in the last few decades, the human race went from being a species that is active most of the time to one that is increasingly sedentary. The Lancet recently called it an “inactivity pandemic,” responsible for 1 in 10 deaths worldwide. That’s a major shift, and a major public health problem, many researchers have pointed out. Inactivity is linked to heart disease, diabetes and some types of cancer.

Now Michael Joyner, a physiologist at the Mayo Clinic, argues in a commentary out this month in the Journal of Physiologythat one way to deal with the problem is to make physical inactivity a mainstream medical diagnosis. It’s one of the most common preventable causes of illness and death, and Joyner writes, there is “one universally effective treatment for it — exercise training.”

Shots called up Joyner to get him to elaborate a little more on just why doctors need to get more involved with this problem.

“The entire medical research industrial complex is oriented towards inactivity,” he tells us. Insurance companies will reimburse patients for pills for diseases related to inactivity, but rarely for gym memberships. “Physicians really need to start defining the physically active state as normal,” he says.

Joyner says that he thinks about 30 percent of the responsibility to fight inactivity should fall on the medical community. “Physicians need to interact with patients about being active, and they need to write prescriptions for exercise,” he says.

He points to two of the greatest public health triumphs of the 20th century — improvements in traffic safety and the decline in smoking rates — as models for how we should tackle the inactivity epidemic. About one-third of the behavior change came from individuals who started using seat belts and car seats, and those who quit smoking, and doctors directly influenced that, he says. The rest was up to the public health community — to enact indoor smoking bans and harsh drunken driving laws — that helped support the right behavior.

For inactivity, doctors can push patients to get exercise, and cities and towns can make it easier for them to do it, he says, with more bike lanes and parks that can be an alternative to the gym.

Joyner says he increasingly sees two types of patients in his clinic: the ones who follow health guidelines and keep active; and those whose don’t and see no connection between their behavior and their health outcomes.

“We have to be more innovative and creative to figure out how to help the people who aren’t empowered to exercise for their health,” he says.

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Family Medicine Is …

Family medicine is:
1) Learning via Facebook that the preteen girl you took care of ten years ago just finished a veterinary medicine fellowship and has started her own practice.
2) Being invited to the Bastille Day celebration hosted by the French Consulate by two patients who are Holocaust survivors.
3) Telling medical students and residents that their stories about their desire to be family doctors resonate as much with politicians as reams of policy papers.

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