Annals of Internal Medicine tip sheet for March 19, 2013

More than 20 years ago, the Americans with Disabilities Act (ADA) mandated that all medical practitioners provide "full and equal access to their health care services and facilities." However, a telephone survey shows that many medical and surgical subspecialty practices are still unable to accommodate patients who use wheelchairs. Using a "secret shopper" type survey approach, researchers called medical and surgical subspecialists in four U.S. cities (Boston, Dallas, Houston, and Portland, OR) to make an appointment for a fictional patient who uses a wheelchair and is unable to transfer from the chair to an exam table. Of 256 surveyed practices, 56 (22%) reported they could not accommodate the patient. Practices' inability to accommodate the patient was rarely due to building inaccessibility (9 practices). More frequently, practices were inaccessible because they were unable to transfer the patient to a table in order to perform an exam (47 practices). Inaccessibility varied by subspecialty. Gynecology was the subspecialty with the highest rate of inaccessible practices at 44 percent, while just 6 percent of psychiatry practices were inaccessible. Of 200 accessible practices, 67 (33%) reported they had equipment that could adjust to the patient while sitting in the wheelchair (e.g., otolaryngology, ophthalmology) or, in the case of psychiatry, that they did not need to move the patient for an exam. One hundred and three practices (51%) reported they planned to "manually transfer" the patient from her wheelchair to a non-accessible high table without the use of a lift. Only 22 practices (11%) reported the use of accessible tables or a lift for transfer. According to the lead study author, the survey results provide one possible explanation for the health care disparities observed in the wheelchair-bound population. The author of an accompanying editorial writes that height-adjustable examination tables could solve the access problem, but the ADA does not specify standards for exam table accessibility. The authors and the editorialist agree that physicians need to be educated about ADA requirements so they can improve access to care for patients with mobility impairments. A summary of this article is free to the public.

The link http://www.annals.org/article.aspx?doi=10.7326/0003-4819-158-6-201303190-00001 will be live at 5:00 p.m. on March 18.

Note: For an embargoed PDF, please contact Megan Hanks or Angela Collom. To speak with the author, please contact Ben Craft at benjamin.craft@baystatehealth.org or 413-794-1689.

Considering the potential for adverse effects, hydrochlorothiazide may be a safer treatment than chlorthalidone for elderly patients with uncomplicated hypertension. Hypertension is a very common condition that is responsible for more than one of every eight premature deaths nationwide. Diuretics are commonly prescribed to treat hypertension, and recent reports suggest that chlorthalidone may work better than hydrochlorothalizide. Researchers reviewed health records for 29,873 patients aged 66 years or older who were newly treated with chlorthalidone (n = 10,384) or hydrochlorothiazide (n = 19,489) to compare the effectiveness and safety of the treatments. For the primary outcome, a composite of death or hospitalization with myocardial infarction, heart failure, or stroke, there was no statistically significant difference between the two groups. However, patients taking chlorthalidone were three times more likely to be hospitalized for low potassium (hypokalemia) and about 1.7 times more likely to be hospitalized for low sodium (hyponatremia) than those prescribed hydrochlorothiazide. The authors conclude that in the absence of hard data on the superiority of either chlorthalidone or hydrochlorothiazide, physicians who care for elderly patients should be mindful of the risk for electrolyte abnormalities in patients taking diuretics.

A link to this article http://www.annals.org/article.aspx?doi=10.7326/0003-4819-158-6-201303190-00004 will be live at 5:00 p.m. on March 18.

Note: For an embargoed PDF, please contact Megan Hanks or Angela Collom. To interview the lead author, please contact Leslie Shepherd at shepherdl@smh.ca or 416-864-6094.

A Chinese herb used in remedies for common ailments such as eczema, acne, liver symptoms, arthritis, and chronic pain remains a worldwide health threat due to its availability online. Approximately 20 years ago, a cohort of young female patients in Belgium presented with a rapidly progressive kidney disease. Physicians traced the cause of the epidemic to a weight-loss clinic that had treated the women with a Chinese herb containing aristolochic acid (AA). Today, renal disease caused by AA is referred to as aristolochic acid nephropathy, or AAN. AAN is associated with a high long-term risk for renal failure and also has been linked to urinary cancer. The authors warn that potential worldwide population exposure to AA is enormous. While banned in the United States, the herb is not widely regulated in China or many other countries and can still be purchased over the Internet. The number of persons affected by AAN worldwide remains unclear. However, investigators from China have reported that AA is responsible for thousands of cases of uncategorized kidney disease in their country alone. The authors stress that prevention of exposure to AA is a key public health priority. They call for tighter local regulation of practitioners and outlets of alternative and herbal medicine, as well as a robust international system of surveillance to identify products containing AA.

A link to this article http://www.annals.org/article.aspx?doi=10.7326/0003-4819-158-6-201303190-00006 will be live at 5:00 p.m. on March 18.

Note: For an embargoed PDF, please contact Megan Hanks or Angela Collom. To interview the lead author, please contact Julie Reason at glord-pa@kcl.ac.uk or +44 (0)20 7188 3053.