News and Views From the Literature

Big Beasts

We all have a fascination with extraordinarily large things. The behemoths that clunk ponderously across the pages of fiction or the National Geographic television series seem to command respect for their sheer size and potential danger. But are there such beasts that roam the health care environment, growing seemingly ever-larger and devouring what sustains them with increasing voracity?

The United States health care system is certainly a large beast, consuming as many dollars as the total gross domestic product (GDP) of countries the size of France.

But it is not its absolute massiveness that is of concern—it is the rate of inexorable growth. Spending on the US health care system has grown, year after year, at a rate of 2.4%. In real terms this means that over the past half century the proportion of GDP spent on health care has risen from 6% to 18%. One dollar in every six earned, spent, or turned over is on health in some shape or form.

If this continues, and there are no indicators of the rate flattening out, then in the next 50 years it will be 50% of GDP or 1 dollar in every 2—clearly a fanciful situation. Its unsustainable growth has come about by rising demand and the free enterprise system allowed to find its own level according to market forces in the absence (until recently) of a universal health care system for all its citizens: the Patient Protection and Affordable Care Act.

For many Americans this Act will arrive just in time, as health (or more accurately sickness) costs are rapidly moving beyond their means; medical bills are now “a leading cause of financial harm,” often leading to loss of savings and homes.¹

No other country spends anything near the same percentage of GDP on healthcare; European countries, Australia, and Japan spend between 8% and 12% on health care. It is not as if this extra expenditure results in better care, because by all accepted criteria of health care excellence America is lowly ranked among the wealthy nations, and continues to lose ground.

Using the criteria of death rates, life expectancy, diminished function, and quality of life, the United States has declined in its ranking over the past two decades.² Getting more “bang for your buck” certainly does not apply to US health care.

As with all problems, the first step is recognition that a problem exists. This is so, as more attention is being paid to politics, policies, and pennies than to any other topics in the major American journals this decade. There is no denial, with intelligent, articulate views being raised to define the issues.

Our American colleagues are among the best trained, hardest working, highly organized, and wonderfully equipped medical practitioners on earth. They are in fair and open competition with each other. They have more and better universities, societies, groupings, academic institutions, conferences, and journals, and produce more research and inventions than any other country by a considerable margin. One only has to look at organizations such as the US Food and Drug Administration, the US Preventative Services Task Force, the Centers for Disease Control and Prevention, the Institute of Medicine, the National Institutes of Health, charitable trusts such as the Bill & Melinda Gates Foundation, and the numerous specialist and subspecialist societies and colleges to be impressed by the array of forces for the promotion of medical progress.

On the research level the United States leads in technologic progress, innovative devices, and sharp-end genomic developments. In patient care the public has direct access to the finest investigations, imaging, and interventions available.

There is no lack of plaudits for the American medical machine, no lack of expenditure—so why does the United States not lead in measures of patient health? First, there is no unified health care system. There is fragmentation of control between state and federal systems, and between public and private systems.

Second, there is subservience to the gods of profit, free enterprise, individual liberty, independence, and choice. Pharmaceutical and device manufacturers push prices and legislative boundaries to the limits they will stand, letting market forces, lobbyists, and legal loopholes maximize income.

Third, there is the great divide, the “haves” and “have-nots” in the land of plenty. Not only is the divide between those who can and cannot afford care, it is between those well and poorly educated about risk taking behavior, lifestyle choices, and their own health. The discrepancies appear to be widening; for example, the overall longevity for women has increased by 3 years nationally in the period from 1990 to 2010, but in 4 out of every 10 counties it has actually dropped. Obesity rates are climbing, teenage pregnancy rates lead the developed country statistics by far, and the indigent continue to be last in the queues for primary care and all forms of preventative measures. The divide widens but one hopes that the present political developments will bring some equity.

To the great benefit of all seeking data concerning the state of US health care, a monumental work has been produced called The State of US Health, 1990–2010. Burden of Diseases, Injuries and Risk Factors, by the US Burden of Disease Collaborators.³ Despite its depth and detail, it is readable and pulls no punches, stating that although the country has improved its health, it has not kept pace with other developed nations that have advanced at superior rates.

From the report, which includes the world’s 34 wealthiest nations, the top 12 of the longevity and healthy life expectancy stakes (for women and men combined) are, in order, as follows: Japan (83 years), Iceland, Switzerland, Australia, Italy, Sweden, Spain, Israel, France, Norway, New Zealand, and Canada. The United Kingdom was ranked 19th (3 places down since 1990), and the United States was ranked 27th (7 places down since 1990).

For the United States the diseases and injuries leading to the greatest number of “years of life lost” are heart disease, lung cancer, stroke, chronic obstructive pulmonary disease, and road injuries, followed by self-harm, diabetes, cirrhosis, Alzheimer disease, and colorectal cancer. The top five risk factors were poor diet, consumption of tobacco, elevated blood pressure, high body mass index, and lack of exercise.

On reflection, it is clear that factors within the control of its citizens dominate remediable conditions. The work highlights where effort should be focused by individuals, which is not in more health care but in more self-care. Every person in every country can learn from this major piece of work.

Oral Contraceptive Safety

Oral contraceptives (OCs) are among the most widely used and safest medications in the world. They have an outstanding record in their primary function of pregnancy prevention, giving women control over their reproductive potential, while simultaneously regulating cycle control and menstrual blood loss, providing mood and physical symptom relief, and improving hirsutism and acne.

On the negative side, their use is seen as sinful by the Catholic Church, and OCs are associated with an increased risk of venous thromboembolism (VTE). It appears clear that this thrombogenic effect is related both to the dose of ethinyl estradiol (EE) and the type of progestin in different OCs. This propensity to cause VTE is often headline grabbing, as claims and counterclaims are made for the various generations of OCs and as new products are marketed. Fortunately the results of large studies show consistency, which allows logical clinical decision making.

The latest meta-analysis by Stegeman and colleagues⁴ from the Netherlands compares the relative risk of VTE among various OCs with the population risk of nonusers (Table 1).

Table 1.

Relative Risk of VTE Among Various Oral Contraceptives With the Population Risk of Nonusers

Population Baseline Nonusers: 3 per 10,000 Pregnancy: 30 per 10,000
Second-generation Progestin Oral Contraceptives
50 µg EE + levonorgestrel	5 × baseline
20–30 µg EE + levonorgestrel	2.4 × baseline
Third-generation Progestin Oral Contraceptives
20 µg EE + gestodene	2.2 × baseline
30 µg EE + gestodene	3.6 × baseline
20 µg EE + desogestrel	3.3 × baseline
30 µg EE + desogestrel	4.2 × baseline
35 µg EE + norgestimate	2.4 × baseline
Not Classified by Generation
35 µg EE + cyproterone acetate	3.9 × baseline
30 µg EE + drospirenone	3.9 × baseline

Figures are approximate. EE, ethinyl estradiol; VTE, venous thromboembolism.

Cesarean Delivery for Twins?

Should twins be delivered by elective cesarean delivery (CD)? With more naturally occurring sets of twins due to increasing maternal age and multiple pregnancies from assisted reproduction, this is an important consideration, especially given the low threshold of resort to CD in most developed countries.

In an attempt to resolve the question, a randomized controlled trial was conducted in 25 countries over 7 years in which, in uncomplicated twin gestations, delivery was mandated to planned CD or planned vaginal delivery.⁵ The gestational window was 32 weeks to 38 completed weeks of gestation, with the leading twin in cephalic presentation; the obstetrician was entitled to resort to CD ante-or intrapartum at his or her discretion.

CD rates were 90% in the planned CD group and 44% in the planned vaginal delivery group. The fetal or neonatal morbidity and mortality rates were the same for both groups in the overall analysis. There were increased adverse perinatal outcomes for the second twin, but CD did not reduce this risk. The authors conclude that there were neither benefits nor harms to the fetus in a planned CD or vaginal birth in twins with an uncomplicated pregnancy in which the first presentation is cephalic presentation and the gestational age is between 32 and 38 weeks.

Whether these data will change policy or behavior is up to obstetricians, but the evidence is now there for them to formulate their own actions.

Drugs in Pregnancy

Fluconazole

The safety of antifungal medications is important in pregnancy as these agents are frequently used for the treatment of vaginal candidiasis at all stages of gestation. Anecdotal reports have linked high doses of fluconazole (given for severe infections in early pregnancy) with specific birth defects, but studies of conventional doses do not support these findings.

The latest report from Mølgaard-Nielsen and associates⁶ uses the Danish birth registry to track the use of oral fluconazole in pregnancy and possible teratogenic outcomes. The researchers found no associations between the previously cited defects and the use of azoles at any phase of gestation either vaginally or orally at any of the recommended dosages. The suggestion of an association with the tetralogy of Fallot amounted to a very small absolute risk; therefore, this large cohort study provides comprehensive information about the safety of fluconazole in pregnancy.

Antidepressants

Women in their reproductive years are known to be above-average consumers of antidepressants, of which selective serotonin reuptake inhibitors (SSRIs) are the most popular. SSRIs are associated with an increased risk of bleeding, so Palmsten and colleagues⁷ researched the association between antidepressant use and postpartum hemorrhage.

The work in the United States did reveal a connection between current antidepressant intake and excessive blood loss following delivery. Rates of 2.8% in the population at large rose to 4.0% depending on the medication used and the timing of exposure. All antidepressants, not only SSRIs, were implicated. In a linked editorial, Heerdink⁸ states that the absolute numbers are small but it is a factor of which clinicians should be aware. Duly noted.

Snippets

Sling or Physiotherapy?

Pelvic floor muscle training is regarded as the first-line management of stress urinary incontinence. The inability to remain continent on physical exertion or raising intra-abdominal pressure is a condition that negatively affects many women, but is it logical to try physiotherapy first or proceed directly to surgery when the complaint is classified as moderate to severe?

To try to resolve this issue a randomized trial of initial professional physiotherapy was compared with initial midurethral sling surgery in a cohort of nearly 500 women in the Netherlands.⁹ After 12 months the subjective improvement rate was 65% for physiotherapy and 90% for surgery. Subjective cure rates were 55% and 85%, respectively, and objective cure rates were 75% and 60%, respectively.

The researchers concluded that measured at 1 year the rates of improvement and cure were strongly in favor of initial surgery. These are useful data to convey to patients.

Wiping or Suction for Neonates?

Doctors delivering babies should ensure that the umbilical cord is clamped late and that the baby is given to the mother as soon as appropriate. Breast feeding should be initiated and vitamin K given immediately.

Should oral or nasopharyngeal suction be part of the correct routine following delivery of term fetus? The answer is no—all that is required is wiping the mouth and nose with a towel. In a trial comparing suctioning and wiping, Kelleher and coworkers¹⁰ found no difference as measured by the infants’ respiratory rates after 24 hours. Because suction can cause trauma or vagal stimulation, and it requires apparatus, it should not be the procedure of choice.

This is good news to those who believe that the process should be as natural as possible, and in areas where resources are limited.

Ig Nobel Awards

The Journal Article Summary Service’s editor is a firm fan of the Ig Nobel awards, as he takes himself not at all seriously. These are awarded (by real Nobel laureates) at Harvard University each year for studies that “first make people laugh, then make them think.”¹¹

The medical award went to Masanori Niimi and colleagues, from Japan, for proving that music played postoperatively to recipients of heart transplants was associated with longer survival times—in mice. They especially liked Giuseppe Verdi’s La Traviata, which more than trebled their duration of life, suggesting to the researchers that the brain could control the immune system.

Another award jointly for entomology and astronomy went to Eric J. Warrant and his team from Sweden and South Africa, for discovering that dung beetles navigate in the dark using the Milky Way to orientate when they get lost.¹²