Archive for June, 2014

Long-term acute care hospitals

Monday, June 30th, 2014

An article in The New York Times (NYT) several days ago opened a new topic and re-visited an old discussion in our household. The title was telling, "At These Hospitals Recovery is Rare, but Comfort is Not" and talked about what Medicare calls long-term care hospitals (LTCHs). I had never hear of the term.

The article said there were 400 of these facilities in the United States, but lots of practicing physicians are unaware of them. I did an online search and found a 20-bed facility in thus category about 15 miles from where we live and a 63-bed hospital in Denver, roughly 65 miles away. I wasn't sure of any in the southeastern part of Wyoming, 40-50 miles north of us.

The Medicare website on Long-Term Care hospitals says they focus on those whose inpatient stay is likely to be more than 25 days. The contrast is stark as this is an age when many surgeries are done in a technically "outpatient" fashion (the current definition of an inpatient says you're in the hospital at least two midnights). Medicare says LTCHs specialize in treating patients, even those with more than one serious medical condition, who may improve with time and eventually return home.

Yet the NYT piece talks of patients who are critically ill, may be unresponsive, even comatose and, except for those who are younger and have been in an accident, may stay for months, years, or the rest of their lives. In 2010 another NYT article discussed significant issues with some LTCHs.

At that point my wife and I both said, "Don't put me in a LTCH!" We are 73 years old, relatively healthy at the present time, and enjoy life. We have living wills and medical durable power of attorney documents naming each other as first decision makers if we can't choose for ourselves.

I've mentioned before how my parents approached this quandary. Mom had a cardiac arrest at age 74, was resuscitated by Dad who was still a practicing physician, and lived 16 more years. But when she was in her declining last four years and they had moved from totally independent living to a seniors' residence, they encountered a situation that influenced their future decisions. Mom had a minor acute illness and moved short-term into an associated facility.

She was there for a few days to get some antibiotics and nursing care, but in the next room was a woman, the wife of one of their friends, who had been in extended care for seven years. For the last four of those she no longer recognized her husband, yet he requested treatment of her bouts of pneumonia on three separate occasions. Dad and Mom each said, "Don't do that to me!" They had signed the appropriate end-of-life documents before Mom showed signs of initial dementia.

A 2011 article in Kaiser Health News stresses that making end-of-life decisions can be tough, especially if they aren't made in advance. But a professor of ethics was noted as saying more than 90% of all families who have a loved one in intensive care want to hear prognostic information that will help them make those difficult decisions.

Hospital care has changed..a lot, since I last saw inpatients. It used to be that the physician who organized your treatment was the same one you saw in her or his outpatient office. Now the primary care physicians I know, unless they are part of a residency program, don't see their long-term patients at all when they are hospitalized. Instead patients see an ER doc, a hospitalist (physician whose focus is inpatient care) and, if they go to an ICU, an intensivist.

Intensivists  are physicians who have completed specialty training, often in Internal Medicine or Anesthesia and then take an additional two-to-three year fellowship in critical care medicine (some are triple board certified, in lung disease (Pulmonology), for example. They are often thought of as primary critical care physicians and in major academically-oriented clinics and their associated hospitals (e.g., the Cleveland Clinic), they may provide most or all of the physician care in the ICU.

Do you need an intensivist?

Do you need an intensivist?

The article from the NYT said we spend over $25 billion a year in long-term acute care in the United States., The path to landing in a LTCH often begins in an ICU. The major task for intensivists is keeping patients alive during critical illnesses. That often means deciding on short- or long-term-ventilator support, the possibility of a tracheostomy (a surgically created hole through the front of the neck into the trachea (AKA windpipe) to allow this, feeding tubes of several varieties or long-term intravenous access.

I don't ever want to be on a ventilator long-term. I might allow one short-term if I had a clearly treatable, potentially curable patch of pneumonia, for instance, but I would  want to set a time allowance for that.

When my mother quit eating, her physician wanted to create a long-term method of feeding her, a percutaneous endoscopic gastrostomy (PEG). If someone cannot eat and needs to be fed long term, one method of doing so is to place a PEG tube through the wall of the abdomen directly into the stomach.

This could be done for someone who has had a stroke and is at risk of aspirating food if fed normally. In my Mom's case, by then she had developed significant dementia and Dad said, "We've made our decisions; she is not having a PEG tube."

She could have gone into a LTCH and lived a while longer, but Dad knew that her refusal to eat meant she had come to a logical stop point.

There are an estimated 380,000 patients in LTCHs at present. Some (roughly 10 to 15%) are there for appropriate reasons and have a reasonable chance of recovery; many are not. A study by a Duke critical care specialist found half who enter these facilities die within a year; a majority of the remainder are in "custodial care."

I don't choose to join their ranks.

So there are some decisions that you and your family may want to make. I'd suggest you read the NYT articles and think about what your choices might be. It's never easy, but a careful discussion in advance with your long-term goals in mind makes sense.




Dengue fever and its major Mosquito vector

Saturday, June 21st, 2014

I don't like being bitten by mosquitoes any more than the rest of you do, but worldwide the real reason to avoid them, kill them or alter them is the enormous disease burden they cause. One recent estimate , surprising to me, said "mosquitoes have been responsible for half the deaths in human history." I was aware, having lived as an Air Forced physician in the Philippines and traveled in South America and Africa, that malaria was one enormously dangerous, mosquito-carried disease, but there's a long list of other illnesses that contribute to the threat from these insects.

This one doesn't carry dengue

This one doesn't carry dengue

From 1690 to 1905 major epidemics of yellow fever struck parts of southern and eastern America: Boston, New York, Philadelphia, New Orleans killing over 40,000 people. A 2006 PBS website gives short summaries of nine of the outbreaks and alludes to even larger mortality figures.

And then there's dengue, a disease primarily transmitted by the bite of infected female Aedes Aegypti mosquitoes. They don't make the telltale sound that alerts you to other mosquitoes, they also strike during daytime and may follow their human target, biting repeatedly.

Dengue attacks 400 million people every year world-wide., mostly in the tropics and sub-tropics. Three-fourths of those infected never develop symptoms and of the remaining 100 million, a large majority have a mild to moderate nonspecific acute illness with a fever. But 5% can have severe, even life-threatening disease with terrible joint and muscle pain (It's called break-bone fever), hemorrhages and shock. The World Health Organization estimates 22,000 die from dengue yearly, but other estimates range from 12,000 to 50,000.

The first known case in the United States occurred in Philadelphia in 1780 and was documented by Benjamin Rush, the distinguished physician who was a signer of the Declaration of Independence.

The Center for Disease Control and Prevention (AKA the CDC) has an entire chapter on dengue in its "Infectious Diseases Related to Travel" publication and a shorter version with links for travelers. Their maps of disease distribution focus on warmer areas in Africa, Central and South America, Asia and Oceania.

There has been no vaccine available to prevent the disease and no specific anti-viral treatment for those with severe cases of dengue. Because of known bleeding complications, those who get the dengue are advised to avoid taking aspirin or any of the nonsteroidal anti-inflammatory drugs , AKA NSAIDs, such as ibuprofen.

The continental United States was essentially dengue-free for over fifty years, but marked increases in dengue infection rates have occurred in our hemisphere, mostly in South America and Mexico.

Now Aedes Aegypti is back in Florida, Texas, and Hawaii. The article in The New Yorker mentioned a small 2009 outbreak of dengue in Key West with fewer than 30 cases, but that was the first real brush with the disease there in over seventy years. In 2010 there were twice as many cases. An entomologist (insect specialist) with the Florida Keys Mosquito Control District reminded the reporters that the manner in which the populace lived was crucial; from 1980 to 1999 there were only sixty-four cases on the the Texas side of the Rio Grande and 100 times as many just across the river.

What was the difference? Likely screens on windows, cars with AC running and windows closed and how often people were exposed outdoors. Key West, in a 2013 followup, had seen no further cases, but the World Health Organization called dengue the "fastest-spreading vector-borne viral disease," saying cases had gone up thirty-fold over half a century.

Why has this happened and what can be done about it?

How can we do this?

How can we do this?

Is this another consequence of global warming? After all dengue has appeared in France and Croatia for the first time. But I just watched an online video by Dr. Paul Reiter, a world-famous medical entomologist, who spent much of his professional career at the CDC's Dengue Control branch. It was obvious that he does not believe in man-made global warming (I do) or that any form of global temperature change is responsible for the spread of malaria or dengue.

How about used tires? He thinks they are great incubators for mosquitoes and billions of those tires have been moved around the globe. So Aedes aegypti has adapted to the city, in part because of our habit of having water-containing used tires around the places where we live.

I don't have any old tires in my yard and I change the dog's water bowl and the bird water outside frequently.

A few new ideas are out there: a British company called Oxitec has genetically modified (GM) mosquitoes, making the males able to mate, but also giving them a gene which kills their offspring soon after they hatch. An initial field trial in Brazil was successful in markedly reducing the population of disease-carrying adult females (remember, males don't bite humans for a blood meal; females do).

Further field trials of these GM-mosquities, titled OX513A, have met with considerable opposition and an engineer involved has published a paper examining the ethical issues involved. The lifespan of mosquitoes is short and they don't appear to be a major food source for other creatures; the most significant issue likely is fully informing the people in the test area are who may consider OX513A to be just another threat.

A French pharmaceutical company recently announced an experimental vaccine for dengue was moderately successful in a late-stage, placebo-controlled clinical trial involving 10,000 children in Southeast Asia, reducing dengue incidence by 56%. A similar clinical trial is underway in South America.

It's a bad disease, coming back at us, but perhaps there's some good news on the horizon.