Global Burden of Disease Study (GBD)

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JAMA published a seminal investigation documenting the Health of America compared to other developed countries broken down by disease, risk factors, morbidity and mortality. The massive undertaking involved hundreds of collaborators in thirty-four countries and some highly sophisticated statistics comparing the burden of disease, disability and risk factors. The report here includes the developed countries participating in the Organization for Economic Co-operation and Development.  The State of US Health, 1990-2010, Burden of Disease, Injuries and Risk Factors appears in the August 14 issue of JAMA.[1] If you have any interest in the shortcomings of our health care system or the health of US’s vital human resource, this landmark document is worth the study.

Harvey Fienberg’s editorial on page 585 observes the decline in the US standing among developed nations.  Herein, “results for the United States are presented in detail for the first time.”  The statistics utilized in the study were extremely complex and all inclusive. However, Fienberg points that socioeconomic status relates strongly with mortality[2] and that socioeconomics was not included as a risk factor in this study. The collaborators agreed. The difficulty was in equating socioeconomics across the many cultures in the thirty-four nations that took part in this study.  Fienberg further observes that the assessment for the US as a whole does not account for significant regional differences. However, he does suggest that the framework for assessing the burden of disease is scalable and applicable to states, counties and municipalities.[3]

The statistical terms used in this study include:  Years of Life Lost (YLL) due to premature mortality, Years Lived with Disability (YLD), Disability Adjusted Life Years (DALY), which combines YLL and YLD and, Healthy Life Expectancy (HALE). The article compares these attributes in the thirty-four countries between 1990 and 2010. This monumental study goes beyond all previous reports by including risk factors for disease.

The diseases causing premature mortality, YLL, differed dramatically from those causing morbidity and disability, YLD. In 2010 in the US the big eight YLL were in order: Ischemic heart disease, lung cancer, stroke, COPD, road injury, self-harm, diabetes and cirrhosis. In sharp contrast, the first eight YLD were:  Low back pain, major depression, other musculo-skeletal, neck pain, anxiety disorder, COPD, disorders resulting from drug use, and diabetes.

The risk factors underlying the leading causes for both YLL and YLD diseases were almost the same. The list of risk factors included: Dietary, tobacco, HBP, high BMI, physical inactivity, high serum glucose, ambient particulate pollution, alcohol, drug use and high cholesterol. Dietary risks accounted for over 650 thousand deaths while tobacco use and hypertension accounted for some 450 thousand deaths. Obesity followed closely behind as insurance actuaries have long established. Dietary risks are by far the greatest, but tobacco, obesity, high BP, high blood glucose, sedentary life style, alcohol, cholesterol, drug abuse and air pollution follow in descending parabolic order as causes of disability.

The figure 4 illustration on page 604 in the journal and below reflects the US’s low YLL ranking compared with the thirty three other countries. The cross-index lists countries on one axis and diseases on the other with the ranking for each in the cross-index. The US is 7^th from the bottom following the Check Republic and Chile in overall ranking. Our ranking by the raw longevity score, infant mortality and perinatal mortality reported elsewhere[4] are even worse.[5] The US comes in 38^th in both longevity and infant mortality. The perinatal mortality rates are even worse.[6]

 Figure 4.

Rank of Age-Standardized YLL Rates Relative to the 34 OECD Countries in 2010

Numbers in cells indicate the ranks of each country for each cause, with 1 representing the best-performing country. Countries are sorted on the basis of age-standardized all-cause years of life lost (YLLs) for 2010. Diseases and injuries contributing to YLLs are ordered by the difference between the US rate and the lowest rate in the Organization for Economic Co-operation and Development (OECD) countries for each cause. Colors indicate whether the age-standardized YLL rate for the country is significantly lower (green), indistinguishable (yellow), or higher (red) from the mean age-standardized YLL rate across the OECD countries. HIV indicates human immunodeficiency virus.[7]

Fienberg writes that setting us on a healthier course will require leadership at all levels of government engaging the profession and the public. Indeed it will, but there has to be more. Fienberg mentions social economic status as a risk factor.  One might add the environmental and behavioral factors and look more closely to the dietary risk that jumps out as, not only the leading risk factor, but by a large margin. Poverty and relative poverty may play as important role as nutrition. The prevalence of ischemic heart disease, diabetes, hypertension and stroke implicate diet and obesity as the underlying cause. These too may reflect poverty as the major risk factor. However, looking at chronic kidney disease(CKD) poisoning, cirrhosis, congenital anomalies, pre-term birth problems, the cancers and the neurological, one wonders if there might not be environmental factors present in the US that are not present in the other countries. Staring at fig 4, one notices a divergence between countries that is hard to attribute to genomics, behavior or health care as outlined.

Studying this somewhat overwhelming research should not be limited to government and public health leaders etc. but may be a lesson in diagnosis itself. A medical history without a social, behavioral, environmental and psychological risk assessment will miss many of the causes of and early diagnosis of disease. One must distinguish between a problem and a diagnosis. Look for a primary underlying cause. “Peal away the layers of the onion.” Fienberg urges inquiry at both the social and biological levels. I love his quote, “Trying to understand the causation of disease using only one of these lines of research is like trying to clap with one hand.” Furthermore, we need to study the burden of disease on a smaller scale. It would be fruitful to analyze the burden of disease on a state, county and municipal level. Risk factors may vary by municipality and indeed by individual. Just as Hippocrates tasted the urine, examined every bodily orifice; he considered the weather the environment and nutrition. We too must consider, social, economic, environmental, behavioral, psychological, dietary and genomic attributes -- critical knowledge for the physician diagnostician. 

One might take exception to vague final diagnoses such as cardiomyopathy, chronic kidney disease, lower respiratory infection, community acquired pneumonia etc. One should  look at the specific cause whether a specific organism or a specific exposure. If disease is by definition a maladaptation to the environment, then one must pay as much attention to the environment as to one’s patient. The same must apply to the social and behavioral factors. Asclepian physicians paid great head to the environment, the air, the winds, the weather, the dampness and the water. Great physicians of the past, like Sherlock Homes saw things in the surroundings that others did not. Look again at figure 4. Some of the US rankings are hard to explain by today’s medical knowledge. Why do we have such excellent medical education and such sad outcomes?  Hippocrates prescribed diets in detail. Perhaps our front line clinics should provide a nutritionist as part of the team.

Food additives in the US have become a poison.  Studies clearly show the deleterious effects of pesticides, sodium, sugars etc. Anything remotely addictive added to packaged food products enhances sales but at the expense of consumer health. The lassie-fair food regulatory policies in the US differ strikingly from those in European countries where fresh foods dominate in the markets over packaged foods. Like grandmother said, eat your vegetables! However, you had better wash them first.

Poverty is an unlisted risk factor and may account for some of the dietary problems. Depletion of living standards for the entire middle class may also lead to dietary and other self-abusive behaviors. The sequestration of wealth --as in the dark ages -- may add to the behavioral risks as well. Herman Boerhaave U. of Lyden and French  Academy of Science 1728 said, “The poor are my best patients because God pays for them.” That sentiment may be hard to find in today’s busy practices. The Affordable Care Act at least establishes a principal of health as a critical infrastructure for us all. The perpetuation of insurance, fee for service and administrative burden may fall short of expectations. The European models of health care are more egalitarian. The medical schools represent our only source for the more equitable distribution of health care. University medical schools have a long history of means testing and free care in support of the poor and the medical community, but they are limited in number and distances between. Today fee for service and insurance mandates silence much of the egality that was once universal in medical schools  It would be naive to think that economics and politics are not risk factors.

We have made great strides in reducing smoking, but one has only to look to see the obesity epidemic. Drug use remains an embarrassment, and environmental pollution is still with us -- perhaps more of a problem here than in Europe.  These factors too may account for some of the discrepancies in outcome between the US and Europe.

Accessibility to care, mal distribution of physicians, the licensing of or exemption of fringe-providers, and continuity of care also play a role in our unfavorable outcomes. We are improving but at a retarded pace and at incredible cost. Diagnosis suffers also from the recent trend – all but eliminating autopsies. In the past, autopsy -- the single one thing historically that propelled us forward in scientific and medical knowledge -- has gone out of style. The CT scan is no substitute. Marie Francois Bichat, 1793, brought pathology to the bedside correlating autopsy with clinical observation. The sign over the door to his autopsy room in Paris read, “Death comes to the aid of the living” and indeed it did for two hundred years. There is no substitute for the Clinical Pathologic Conference (CPC). Even the NEJM today presents cases today without autopsy.

If you don’t do a rectal, you don’t use a head mirror, you don’t feel a pulse and you don’t look at the feet, or take off the shirt to examine the chest, then your diagnosis and your outcome will be as limited as your investment in the patient. These are but some of the shortcuts that characterize today’s “industrialized medicine.” When we practice medicine as a business, it is more profitable to skim the diagnostic caldron for high priced procedures, high patient volume and cover the missed and wrong diagnosis with liability insurance and silence. By industrializing medicine we have opened the door for any and all business ventures to feed at the health care trough no matter how marginal or how harmful.  By denying local medical societies the control over professional privileges and professional behavior, we have left the legislature valorized by lobbyists in control of behavior and the hospital, insurance and drug company free reign.

All the great doctors in history had three things in common: they traveled widely to medical centers all over the world, they translated Hippocrates and they had the Gout. I could do without the gout but would add attendance and participation in CPCs. It is time that we visited the successful healthcare systems in Europe and the East to see what works. Instead of revising curriculum by invention, visit the medical schools in other countries, much older than our own and examine their methods. We were leaders in health care for only a brief span of history, mainly during WWI and WWII while 45 years of Cold War brought both the US and Russia the four horsemen of the Apocalypse.  Perhaps it is time for another Flexner Report -- now a hundred years later.

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[1] JAMA,2013;310(6):591-608. Doi:10.1001/jama.2013.13805

[2] National Research Council; Institute of Medicine. US Health in International Perspective: Shorter Lives Poorer Health. National Academies Press; 2013

[3] Katz B. Bradley J. the Metropolitan Revolution. Brookings Institution; 2013

[4]  http://www.enagic.com/enagic_life.php

[5] http://data.worldbank.org/indicator/SP.DYN.IMRT.IN

[6] http://whqlibdoc.who.int/publications/2006/9241563206_eng.pdf

[7] Figure 4 reproduced with permission JAMA RightsLink and Copyright Clearance Center Aug 14 JAMA, Christopher Murray et al; Copyright © 2013, American Medical Association

Gram Stain

Share |While on the subject of crackles, rales and missed diagnosis of pneumonia, how about the ubiquitous culture report, "Normal Flora"? What does it mean, normal flora? First you have got to ask yourself, why did someone order a culture? It was surely because they suspected a bacteria, fungus or TB based on the color, consistency and appearance of the sputum from a productive cough. When the lab reports normal flora and if questioned, offers, "probably a virus," you think, why bother and enter the diagnosis as community acquired pneumonia -- a total cop-out.

Part of the problem is us. We are no longer willing or able to look through a microscope. Medical schools no longer teach microscopy, HICFA or some great bureaucracy in the sky outlaws doctor's office laboratories as unsavory profit centers or dangerously unlicensed in-competencies. We relegate the microscopy to the hospital lab where economics holds a higher priority over patient care. A simple gram stain would usually identify the organism beforehand giving the microbiologist greater motivation. Normal flora does not cause leukocytosis in sputum or the blood count. Many gram stain reports -- you probably have to order it specifically -- numerate gram positive cocci and rods along with numerous gram negative rods and cocci with a conclusion of normal flora; it raises a question of credibility. With multiple forms of Neisseria on the culture plate the same interpretation might be forthcoming 24 hours later. 

A serious look at the gram stain can alleviate much of the frustration  if the physician will just insist on viewing the gram stain. The presence of intracellular bacteria is the first clue. What are the WBCs having for dinner? Is the slide covered with eosinophiles? It takes only a minute to splash on a Hansel's stain or for that matter KOH for a fungus. An acid fast is easy as well. What is the predominant organism? --- Infectious disease physicians and hematologists should have access to a well-equipped shared laboratory bench.

In the future, one might think that it would be in the hospitals financial interest to accurately identify a specific etiology for the pneumonia rather than the generic community acquired code. The diagnostic related group (DRG) reimbursement is far greater for a specific diagnosis. Fluorescent microscopy would go a long way towards specificity and a sharper image as well. Today polymerase chain reaction (PCR) can identify almost any bacteria, virus or parasite. It would serve the hospital laboratory well to invest in leading edge real-time definitive diagnosis of infectious disease. If not, the PCR belongs in the doctor's office.

More Crackles

More Crackles

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 Quoting the NEJM's Resident e-Bulletin 2/20/2014 Teaching Topic Lung Auscultation

"Q. What are the differences between fine and course crackles?

A. Two categories of crackles have been described: fine crackles and coarse crackles. On auscultation, fine crackles are usually heard during mid-to-late inspiration, are well perceived in dependent lung regions, and are not transmitted to the mouth. Uninfluenced by cough, fine crackles are altered by gravity, changing or disappearing with changes in body position (e.g., bending forward). Coarse crackles tend to appear early during inspiration and throughout expiration and have a “popping” quality. They may be heard over any lung region, are usually transmitted to the mouth, can change or disappear with coughing, and are not influenced by changes in body position. Typically, fine crackles are prominent in idiopathic pulmonary fibrosis, appearing first in the basal areas of the lungs and progressing to the upper zones with disease progression. However, fine crackles are not pathognomonic of idiopathic pulmonary fibrosis; they are also found in other interstitial diseases. Coarse crackles are commonly heard in patients with obstructive lung diseases, including COPD, bronchiectasis, and asthma, usually in association with wheezes. They are also often heard in patients with pneumonia and congestive heart failure."

Who is to argue with the NEJM, documented with modern auditory recordings and referenced with a pear reviewed lead article, Fundamentals of Lung Auscultation: Abraham Bohadana, M.D., Gabriel Izbicki, M.D., and Steve S. Kraman, M.D. N Engl J Med 2014; 370:744-751February 20, 2014DOI: 10.1056/NEJMra1302901, "Computer-assisted techniques allow detailed analysis of the acoustic and physiological aspects of lung sounds." 

From a teaching viewpoint there probably is no higher authority than that quoted above, yet some of the computer-assisted observations run contrary to my clinical experience and the teachings from the pre-crackles era. In my experience, fine rales at the left base are the hallmark of left lower lobe pneumonia. They are a fine low pitched sound similar to the sound of rubbing your hair together just above your ear. They do not go away with change in position and they occur in early to mid inspiration. I am not so interested in the computer findings as I am concerned by the missed or misdiagnosed early pneumonia and the sound in my own stethoscope. Pneumonia in the early stages, coincides with the patient's complaint of chills fever and a productive cough. X-Rays are not yet positive but a gram stain confirms the diagnosis. Unfortunately, this is the stage of pneumonia that is often misdiagnosed as a virus and sent home without adequate consideration. The above description of course crackles with pneumonia might come at a later stage of pneumonia's progress when a school teacher can make the diagnosis.

The problem may be that all the pre-crackles physicians are gone now or retired. I read that crackles live only in America. I doubt that with the distribution of today's journals, but I rather imagine that Europe, especially France, would be less willing to give up Rene' Laennec's terminology or diagnostic acumen. I do wonder about the digital rendition of rales, however. Harmonics plays a significant role in the low frequencies and digital may not be able to capture these low frequency analog harmonics. Furthermore, as one of my students commented speakers cannot reproduce the low frequencies. This is evident in the class room when attempting to broadcast heart and lung sounds over the speaker system. When I was in medical school, we had tubes from the examining table in the front of the amphitheater to the back of the chair in front of us with a lure-lock fitting. Our stethoscopes had a lure-lock fitting on a detachable head. We were thus able to attach our stethoscope to the closed system and hear the sounds from the examiner's stethoscope in real time without electronic distortion.

One cannot argue with the NEJM, but medicine is not immune to mistakes and bad ideas. Once they are in print it takes a long time to change them.

Syphilis

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University of Kansas Hospital Dana Hawkinson, head of infectious disease sounded the alarm -- on Valentine's Day -- for a 100% increase in the incidence of Syphilis appearing in all age groups from teenagers to seniors. What is more alarming, Hawkinson claims that these cases are antibiotic resistant.

Nothing that I know of could be more frightening. The world including the medical profession has forgotten the world wide epidemic of syphilis, the mortality and the  suffering it caused, nor do we remember the high degree of infectiousness of that little spirochete. It did not jump off the drinking fountain to infect you, but putting your mouth on the faucet got you. Syphilis was the reason for those thin paper toilet seat protectors you always wondered about.

Naples 1494 French and Spanish alternately occupied Naples. Some Spanish sailers who sailed with Columbus had picked up a strange disease in the Indies. With irresistible tales to tell of their voyage, they quickly passed it on to the ladies of Naples, who in fair turn passed it along to the French. The French called it the Spanish disease and the Spanish, the French disease.

Often confused with leprosy, Syphilis had no effective treatment. All sorts of things were tried. They used Guaiacum, mercury and later heavy metals.  Hieronymus Fracastorius (1483-1553) a physician and a poet wrote– Syphilis sive Morbus Gallicus – the shepherd-sufferer gave the disease its name. (Translated shepherd or swineherd)

Treponema pallidum Because of the extreme effectiveness of penicillin against syphilis, the disease is all but forgotten. Long ago the first laboratory test with every hospital admission was a VDRL or Wasserman. The health department enforced isolation and close follow up with all family and contacts. If we had done that with the AIDS epidemic, it would not have become the killer that it did. The health department today, however, is impotent. Bothe diagnosis and treatment are dictated by politics. The Health Department of old hardly exists. The laissez-faire political solutions favor individual liberties over the common good and motivate treatment for which there is a profit rather than public health for which there is not. Young doctors may not recognize the disease. A microscope is required for the positive identification of a chancer, and microscopy is becoming a lost art among physicians.

2,465 years ago Hippocrates stemmed the tide of the plague in Athens by burning the homes and the bodies of the victims with fires all over the city. A tribal chief in Africa contained Ebola by the same technique and locking down the village. Isolation is the only way to contain an epidemic with the infectivity of syphilis, isolation until the successful completion of treatment. Given a high degree of antibiotic resistance, that isolation might require a tertiary hospital's isolation ward.    

Meanwhile the U of Washington has developed a new condom that is thin, adherent, strongly antiseptic and dissolves after use. I doubt that it will stop the spread of syphilis, however. Mealy kissing, can transmit the disease, and already the distribution throughout all ages including seniors, suggests a complementary non-sexual transmission of the drug resistant spirochete.|

Crackles, an End to Civility and the timely diagnosis of pneumonia

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Rene Laënnec in 1816 fashioned a role of paper in order to listen to the heart sounds in an older obese woman in cardiac distress. Laennec later described the sounds of peripneumonia as rales at the left base of the lungs. Rales translate appropriately as rattles in English, and the term rales prevailed as the ausculatory sound of pneumonia. In referring to rales in front of a French patient, however, there was a problem. The French term for death rattle, `rales d mort,` was common knowledge, and known as a sign of imminent death. Thus, Laënnec substituted the word rhonchi when referencing rales in front of a patient. Both terms remained in common use in medicine and with some confusion between the two. 

I learned rales as the subtle rustling or faint bubbling sound of wet alveoli engorged with purulence during inspiration.  Rhonchi were a coarser sound emanating from more proximal bronchioli – not at all the interchangeable meaning of rales and ronchi as used by Laennec. The continuing confusion over these two terms lead the American Thoracic  Society and the American College of Chest Physicians in 1977 to change the name rales to crackles.

Crackles carry the suggestion of an onomatopoeia; Crackles implies the sound of Rice-Crispi’s. Crackles may mimic the sound of advanced pneumonia, but the sound of rales at the left base at the critically early onset of left lower lobe pneumonia sounds more like rubbing your hair above your ear. It is a subtle sound accompanied by respiratory lag and splinting of the diaphragm –to often missed.

Changes in curriculum, standardized patients, recorded sounds from a manikin, shorter clinical hours, the concern for overuse of antibiotics, the change in name of d-pneumococcus to streptococcus, the protocols for immunizations, cholesterol checks, colonoscopies, conspire to reduce the sensitivity for the seriousness of a patient’s early illness. Early onset pneumonia presents with a patient who is a whole lot sicker than he or she looks. Often the temperature is not so high and the protocols seem to suggest that anything that coughs is a virus. There is even a score called the Risk-Rating-Index that tries to quantify the risk of the patient actually having pneumonia. Without long hours in the middle of the night seeing such patients, the pattern recognition of early pneumonia is lost or never learned.

The treatment is wrong when the diagnosis is wrong. If we diagnose pneumonia only with the second Emergency Room visit after the treatment for the virus that is going around fails, and the patient becomes indeed critical, an easy early treatment with oral agents becomes a hospital admission treating a critical illness all for a failure to diagnose.

 So, crackles it is, but define them as fine, coarse, wet or dry and when in inspiration. Percuss the mobility of the diaphragm. Do a Gram stain and view it yourself. Recognize a critical diagnosis when it sneaks up on you.  They may forgive you for using the more civilized `rales` in the French tradition when your take the extra steps and correctly diagnosis a case of early pneumonia.

FREE INFORMATION

Share |Hippocrates said that sacred knowledge should not be given to the uninitiated. He also said we should share information freely among ourselves. Copyright locks up the best of medical thought behind monetary walls. When I first went into practice, I could not afford journals. I was too busy paying off debt. In family practice, I needed many journals to stay current, but the family doctor who needs them most can afford them the least. The specialist who can afford all of them wants only one or none at all.

Now we have the Internet and Google. People can access anything, but not physicians. The hospital, medical school or medical society library is the only access without a high priced subscription. Now that I am semi retired, I have none of those things available, but it is the older physician who needs current information the most. Restricted access to medical knowledge is a good thing on the one hand; there is too much mischief to be made in sharing critical knowledge with those who would misuse it. Price, however, is not the way to channel medical knowledge. Better that we make all knowledge free and take our chances.

The medical schools do us a disservice by not providing total online access to all publications through their medical library. Without access to free medical information, we are left with best evidence determined by someone else, of an unknown source, unknown date and unknown validity. The guideline stifles progress. The guideline provided by someone else ends clinical medicine as a science and clinical doctors who rely entirely on those guidelines as scientists. 

Standardized medicine has some merit, however, in shoring up clinical weaknesses, excesses and greed. Such standardization may be the only way forward from our broken profession, but by the same argument, published research and clinical information needs to be freely distributed within the profession. Neither copyright nor patent should interfere.We need free access to all medical  information. No wonder an office visit costs so much.