Are Annual Health Check-Ups Of Any Use?

Comprehensive health check-ups have become all the rage. There is a general feeling that doing a non-targeted check-up once a year helps pick up disease early and prevent future problems.

For corporate chains, health check-ups have become big businesses to the extent that many chains have actually opened out-patient health check-up centres that include “5-star” facilities that we otherwise find only in spas and high-end beauty salons.

The problem of course is that there is no evidence that non-targeted health check-ups in asymptomatic individuals work. Not only that, there is a real possibility of harm, both physical and emotional with such testing, especially when non-important pathologies are picked-up.

To elaborate further. Getting a colonoscopy done once every 5 years after the age of 50 to look for colon cancer and polyps has been proven to save lives. Getting a mammogram done every one or two year after the age of 50, though not without recent controversy, is also known to save lives. Blood pressure measurements and blood sugar evaluation help as well. Beyond these, unless there are symptoms or a high possibility of specific disease, non-targeted health check-ups and packages have no relevance.

This particular piece titled “The 50,000 USD Physical” is an interesting narration of what can go wrong with a health check-up. Coupled with these guidelines from the Society of General Internal Medicine, this article should serve as a warning lesson to all of us in the fraternity involved with health check-ups in asymptomatic individuals.

Treatment for Idiopathic Pulmonary Fibrosis

As everyone working in this field knows, the prognosis of idiopathic pulmonary fibrosis (IPF) is quite dismal (3 years survival of 50%). There have been many treatment regimens that have been suggested, but it is not clear whether any of them are of any use.

The latest issue of the New England Journal of Medicine (NEJM) has 3 articles and one editorial on this subject. The last one on acetyl-cysteine confirms that it does not really work.

However one more phase III trial by Talmadge King’s group on the use of pirfenidone, conducted because the US FDA was not convinced about its efficacy given the conflicting results from previous trials, shows that it does improve decline in lung function and overall survival.

The paper that however does bring a smile and some more hope is the first one by Richeldi Luca et al that shows the usefulness of nintedanib (where do come up with these names) in improving the reduction in FVC in patients with IPF.

There is a lovely short commentary / editorial that puts all these papers in perspective and even addresses the question of whether both nintedanib and pirfenidone should be used together and whether that would help even more or not. This is an interesting thought.

All of these are must reads for all those who have patients with IPF whose care they are responsible for.

 

PSA Guidelines

This may seem like an unusual post in a radiology blog, but those who do body imaging often get asked about the relevance of PSA levels by patients.

This nice article in the BMJ makes at least one thing clear. If in a > 60-years old male, the PSA is < 1ng/ml, we don’t need to bother.

Statins and Contrast-Induced Nephropathy

There is an amazing amount of focus in the cardiology literature on the issue of contrast-induced nephropathy (CIN) with intra-arterially injected iodinated contrast media.

This week’s issue of JACC (Journal of American College of Cardiology) has two articles on the use of statins (in this case, specifically, rosuvastatin) that reduces the risk of CIN in high-risk patients undergoing catheter coronary angiography. The first article by Han et al has a larger group of patients who are diabetic and have mild to moderate CKD whereas the second article by Lencioni M et al has a smaller group of patients who presented predominantly with non-ST segment acute coronary syndrome.

In both articles, the patients were well-hydrated. Both have a control group that did not receive statins and both articles unequivocally show a reduction in the incidence of CIN.

Whether this is applicable to patients undergoing contrast administration during computed tomography is uncertain.

The overall incidence of CIN in practice is low and if we stick to the basic principles of evaluating the renal function in those at risk and using hydration and low-ionic contrast media, we can pretty much reduce the risk considerably. It is a good idea to re-evaluate all of this by going through the 2013 edition of the ACR criteria and a lovely review article by a Jorgensen Ann, a nurse. Many of us also use acetyl-cysteine, but the data regarding its efficacy is not very robust.

As usual, if you need copies of the JACC articles for personal perusal, send me a request.

Arthroscopy versus sham

These are the kind of studies we need more off. Clearly, when the same was done for vertebroplasty versus sham, it raised the hackles of everyone in the radiology world, because two independent studies showed that vertebroplasty was no better than a sham procedure. Of course that controversy in no way seems to have dampened the use of vertebroplasty.

This week’s NEJM has an article that discusses the value of arthroscopic surgery for meniscal degeneration in patients with osteoarthritis and finds the results no better than sham surgery. We already know this intuitively and from anecdotal experience and this is one of the reasons not to overcall meniscal degeneration as tears to prevent unnecessary arthroscopic exploration of frankly osteoarthritic knees.

Suffering

This article by Lee T H in the recent issue of the NEJM actually discusses “the word that shall not be spoken”, i.e. “suffering”. What is even more interesting is that he describes this in the context of a healthcare company’s business strategy – to reduce suffering from disease, from complications and from dysfunction of the delivery system.

It is an interesting thought and an article worth reading.

If you would like a copy, please email a request.

 

The Master Surgeons

Dr. Pauline Chen as a piece in the NY Times about how the skill of a surgeon makes a huge difference, but has always been difficult to measure.

And yet, by word of mouth, it has always been possible to know of surgeons who are “amazing”, “lightning fast” and “gifted”. The anesthetists, nurses and resident surgeons are in the best possible position to compare and evaluate, along with the surgical ICU doctors. This knowledge obviously rarely gets passed on to patients.

It is the same in radiology. All radiologists are not and can never be the same, which is why radiology cannot be commoditized or “teleradiologized”. And over a period of time, everyone in the community knows who the brilliant ones are, both from a diagnostic as well as an interventional perspective. The patients may never come to know.

The Typical Radiologist Work-Day

This is the kind of article that should be completely free, but is unfortunately behind a paywall . This article by Dhanoa D et al in the J of the American College of Radiology tracks the typical workday or hospital radiologists in 3 hospitals in British Columbia in Canada and not surprisingly comes up with final conclusion, though they don’t use these words per se, “radiologists are not image-readers – they are physicians who are actively involved in patient management using tools of image interpretation and intervention”.

For those of you who want a copy, email me or leave a comment with your email ID and I will send you the article.

The take-home points are:

  • Local on-site radiologists spend 36.4% of their clinical time on image interpretation.
  • 43.8% of on-site radiologists’ clinical time is spent on noninterpretative activities, such as quality assurance tasks, patient safety responsibilities, and image-guided procedures.
  • The total clinical productivity of on-site radiologists is 87.7%.
  • On-site radiologists experience an average of 6 inter- actions per hour with health care personnel, of which 81.2% directly influence patient care in the medical imaging department.
  • Replacing the on-site radiologist discounts the value of their noninterpretative activities, suggesting a loss to the provision of high-quality patient care. 

Essentially, an on-site radiologist is critical to patient management.

This would even translate to diagnostic centers, where even though there is reduced direct interaction with treating physicans and surgeons, the amount of time spent on the phone or other methods of communication interacting with referring doctors with respect to appointments, scheduling the correct study for the correct clinical situation, monitoring studies, contacting the doctors with provisional and final reports and ensuring proper patient flow, as well as dealing directly with patient queries, etc. takes up a significant amount of time. At best, even in an optimized private practice workflow situation, a radiologist is unlikely to spend more than 50% of his/her time actively looking at images.

 

Thyroid Ultrasound Criteria to Diagnose Possible Malignant Tumors

There are so many important articles that do not get published in the radiology literature.

The recent issue of JAMA Internal Medicine has an article by Smith-Bindman R et al that discusses how to use thyroid USG signs to decide which nodules need to be biopsied.

Three criteria are important – microcalcifications, completely solid appearance and size greater than 2 cm. If we stringently follow the rule that at least two of these criteria have to be present before performing thyroid nodule biopsy, then the sensitivity would be reduced but with a high positive predictive value, but without compromising the ability to pick up malignancy. It is worth reading the article to understand the importance of large population based studies to help us use our radiology signs to better triage patients.

 

Social Media and Doctors

This is an interesting article in the recent JAMA by Lerner B discussing what is appropriate and what is not as far as the use of social media in medicine is concerned, especially at the level of resident doctors.

Not friending patients, not posting compromising pictures online, not discussing inappropriate issues including sexual and otherwise are standard, quite obvious points that need to be followed by all.

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