Hopkins PodBlog

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2010-12-02T07:09:00.000-08:00

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Ice Hockey, Body Checking, and Injury in Kids

2010-06-11T06:11:00.000-07:00

Is body checking absolutely fundamental to ice hockey? No doubt ice hockey fans would roar a resounding yes! but a study in this week's JAMA illustrates just how dangerous body checking is for neophyte hockey players in Canada.

Turns out Canada has some fascinating social experiments percolating, and this is one of them: in the province Alberta, body checking is allowed among PeeWee hockey players. Those are players 11-12 years old. In Quebec province, this practice is forbidden. Researchers crunched data from the top 60% of divisions of play for the 2007-2008 ice hockey season for both leagues, representing close to 2200 players.

The data show that when Alberta players were compared with Quebecoise, the former were at a three fold higher risk for concussion, severe injury, and severe concussion. There was no difference in rates of injury for the two study groups experienced during practice, when presumably, players aren't body checking each other with a view to a kill.

Risk factors for more frequent injury included smaller body size and hours of play, while severe concussion was associated with position played and the player's attitude toward the practice of body checking. Clearly the take home conclusion is that if we want to reduce injuries, some of them severe, to young hockey players body checking should not be allowed. It's unclear to me why body checking is necessary at all at any level of play, but I guess hockey fans are a bloodthirsty lot, and as Rick quips in the podcast, "I went to a boxing match and a hockey game broke out," perhaps it is expected.

This study is published at a time when concussions experienced while playing sports are receiving a lot of media attention. A week ago I attended an NFL/Johns Hopkins conference on 'mild traumatic brain injury,' or concussion, sponsored by the NFL. The central question is what is the risk of repeated injury on the subsequent development of dementia or other health problems later in life? Other questions identified during the conference included ways to assess severity of injury, appropriate recuperation periods before returning to play, and others. A dearth of evidence is apparent, as is the need for considerable research to convincingly answer these questions. But here's one thought that occurs to me: professional football players choose to play football, but PeeWee hockey players are not in a position to assess evidence and make informed decisions, and therefore protective measures must be undertaken by coaches and parents. If we're worried about the deleterious health impact of head injury in adults, what are the consequences in children?

Other topics this week include a new use for an old drug: allopurinol and angina in the Lancet, nonsteroidal antiinflammatory drugs and cardiovascular risk in Circulation, Cardiovascular Quality Outcomes, and abuse of prescription medications in US teenagers from the CDC. Check out our YouTube, and until next week, y'all live well.

Brush Those Teeth!

2010-06-04T11:03:00.000-07:00

As I opine in this week's podcast, it seems curious to me that so many of our body parts are treated separately, as though feet, backs, and teeth were distinct entities. Indeed, I've often thought it would be great to simply drop my teeth off at the dentist and come back later to retrieve them but the fact is, they're attached to my jaw, and therefore to me and the rest of my body. Further evidence of their inextricable link emerges in a study in BMJ: Toothbrushing, inflammation, and risk of cardiovascular disease.

This study took a look at how often folks brushed their teeth (almost 12,000 of them! That's people, not teeth) and how that correlated with cardiovascular events, such as heart attacks or strokes, over an average follow up period of 8 years. Three levels of tooth hygiene were possible: less than once per day, once a day, or twice a day. Sure enough, there was a dose response. Those who brushed their teeth least were at the greatest risk of a cardiovascular event, with about a 70% greater chance of experiencing a heart attack or stroke compared with those who brushed twice a day. Seems compelling to Rick and me that twice a day interaction with a toothbrush is a good idea.

The study also measured blood levels of C-reactive protein, one marker of inflammation, and fibrinogen, a blood component related to clotting, in almost 5000 participants. Once again, higher levels of both of these blood markers were associated with less frequent tooth brushing.

Things not assessed in the study I would like to see would be flossing in addition to brushing, since presumably more of the bugs that reside in our mouths and may cause low grade inflammation are removed when we floss, and perhaps use of mouthwash and its potential impact. The inescapable conclusion, though, is that our oral health does impact general health. And as Rick points out, not only will our bodies be grateful for vigilant oral hygiene, so will those around us.

Other topics this week include treatment of one partner who is HIV positive and preventing infection in the other partner in the Lancet, timeliness of treatment for heart attack in JAMA, and group medical appointments in Annals of Internal Medicine. If you haven't looked at our YouTube we'd be so happy if you did! and until next week, y'all live well.

Common Diabetes Drug and Vitamin Deficiency

2010-05-28T05:30:00.000-07:00

I'm a big fan of the tried and true when it comes to medications and procedures. After tens of thousands or even better, hundreds of thousands of people have run the gauntlet, I too, am much more willing to give things a try. Call me a coward, but I get a big lift from following the crowd in this regard. So if I had type 2 diabetes I would be okay with taking metformin (after trying weight loss and dietary changes, of course). But now a study in the current issue of the British Medical Journal raises a red flag about metformin use: it may cause vitamin B12 deficiency.

In this long term study of several hundred people who were given metformin or placebo three times a day for an average of 4.3 years, those who received metformin saw a reduction in their levels of vitamin B12 of about 19%. People taking metformin also experienced an increase in homocysteine levels, a marker of cardiovascular disease risk, assumed to be caused by the decrease in vitamin B12.

Yowl! So what's a responsible person with diabetes to do? Uncontrolled diabetes is a major risk factor for cardiovascular disease, and now one of the most trusted agents for managing the condition may also precipitate increased risk? And when the other drugs used to manage type 2 diabetes are considered, things look bleak indeed.

Steady, now. Although the effects of vitamin B12 deficiency at the low end may include fatigue, poor memory and depression and at the high end, irreversible damage to the brain and other parts of the nervous system, the authors of this study suggest that simply measuring blood levels of the vitamin is a simple and prudent step. Those who are found to be deficient can first try consuming foods rich in B12: meats, fish, and milk and milk products among them. If these don't correct the problem supplements may be the answer. But there's no compelling reason to avoid metformin use as long as there's awareness of this possibility. And that's good news.

Other topics in this week's podcast include drowning prevention in Pediatrics, the dangers of multifocal eyeglasses in the elderly in BMJ, and sugar sweetened beverages and blood pressure in Circulation. Watch our YouTube, and until next week, y'all live well.

Depression in New Dads

2010-05-21T06:59:00.000-07:00

Maternal depression is a common condition following childbirth, and its negative consequences for all concerned have been studied extensively. Now it turns out that dads, too, suffer a high rate of depression following the birth of a child, a study in the current issue of JAMA reports.

Depression in both parents can develop prior to the birth of the child, but this study reports it most often happens afterward, when the baby is three to six months old. Makes a lot of sense to me! I remember those days without regret that they are over. I would add, especially after the birth of my first child, that it was so much more life-altering than I had any idea about. Add to that sleep deprivation, worry about parenting skills or their lack, mountains of laundry, frequent pediatrician visits, and it's no wonder depression ensues. And my children were healthy and my deliveries uncomplicated. How much worse for those who don't have such good fortune.

I write, of course, from the maternal perspective, but this study shows that about 10% of the men who participated in reviewed studies, since this was a meta-analysis, experienced depression. Frequently it was correlated with the development of depression in the partner, and this too makes sense. One of the concerning aspects of the study is the fact that depression on the part of the father, just like that in mothers, may also contribute to negative outcomes for the child.

So what can we do about this depression? One clear answer is to screen for it, especially among partners of women who develop depression during this period. The findings suggest that families should be treated as a unit and screened as such. The big question is how should such depression be treated? The answer is beyond the scope of this study but certainly suggests a direction for future research. In the meantime it may provide comfort to men who experience depression following the birth of their child that it's not an aberration and it's okay to seek help.

Other topics in this week's podcast include depression following traumatic brain injury in the same issue of JAMA, an individual's risk for developing resistant infections with antibiotic use in BMJ, sildenafil or Viagra in a lung condition called pulmonary fibrosis in NEJM, and pesticide residues and risk of ADHD in children in Pediatrics. Please check out our YouTube and until next week, y'all live well.

Managing Your Upset Stomach

2010-05-17T08:45:00.000-07:00

Proton pump inhibitors are a very popular form of antacid medication usually abbreviated PPIs. They're available in both prescription and over the counter (OTC) strengths, and the latest issue of Archives of Internal Medicine states their prescription-only sales total almost $14 billion per year. Only the manufacturers know what the OTC sales are worth, but what's emerging in this issue of Archives is a rather concerning picture of the multitude of side effects related to use of PPIs.

Turns out that women in the Women's Health Study who took PPIs had an increased risk of fractures of the spine and lower arm. Patients who took PPIs and were hospitalized had a much heightened risk of becoming infected with that increasingly frightening pathogen, Clostridium difficile. C. difficile, for those in the know, causes diarrhea, often bloody, and can be very challenging to eradicate. And those on PPIs are also more likely to develop both hospital- and community-acquired pneumonia. Yikes! How then can we account for the popularity of PPIs?

Many people are placed on PPIs (and probably shouldn't be) when they're hospitalized and when they're discharged they simply stay on the medication. About a quarter of US adults report dyspepsia, medicalese for upset stomach or indigestion, and these drugs are very effective at treating it. Physicians accustomed to providing relief may prescribe PPIs. But the author of an editorial states that between 53 and 69% of prescriptions for PPIs are NOT indicated.

So, hmmmm. Seems we have a very effective medication for a common complaint that's costing our healthcare system a lot of money and that looked to be innocuous but now isn't. Clearly, PPI use needs to be scrutinized very carefully. What are the alternatives?

First of all, prevention, as always, is worth a pound of PPIs. Don't eat large meals late at night and then go to bed. Curtail consumption of wine, coffee and perhaps chocolate before retiring. Sleep with your head elevated. Lose weight if you need to.

So you overeat and go to bed. Then what? Start with the little guns first. Garden variety calcium-based antacids can be very effective, and then perhaps reach for the class of antacids known as H2 blockers, which although still associated with side effects don't seem to be quite as deleterious as PPIs.

Other topics in this week's podcast include the benefits of consuming nuts in Archives, the real incidence of food allergies in JAMA, and the effect of fibrates on cardiovascular risk in this week's Lancet. Until next week, y'all live well.

Celiac Disease Diagnosis

2010-05-10T05:35:00.000-07:00

Before launching into this week's blog on celiac disease, Rick and I would like to invite you to view our YouTube. And now, on to the topic at hand:

Lots of people complain of gastrointestinal symptoms. In point of fact, this week's meta-analysis on diagnosing celiac disease in JAMA states that between 35 and 40 individuals out of every 1000 who visit their primary care doctor do so because of abdominal discomfort, bloating, diarrhea, or other chronic symptoms, and these can adversely impact quality of life.

Among the plethora of conditions that can cause chronic abdominal distress is celiac disease, with an estimated prevalence (medspeak for how many people have this in the population at large) of 0.5%-1.0%. That's a lot of people. And what exactly is celiac disease?

Celiac disease can be defined as a sensitivity to gluten, a protein found in wheat, barley and rye, that largely affects the small bowel or intestine. This sensitivity gives rise to nonspecific symptoms such as diarrhea and bloating, but can have long term consequences, including fertility problems, osteoporosis, and cancer. The best news about celiac disease is it can be managed very well by avoiding foods that contain gluten. Few conditions respond so well to such simple intervention.

Since both cause and cure are well known, diagnosing celiac disease properly is pivotal. This analysis makes the case that abdominal symptoms alone are not sufficient to diagnose the condition, and that two blood tests, used sequentially, may be the way to start. IgA antitissue transglutaminase antibodies and IgA antiendomysial antibodies are two types of antibodies found circulating in the blood in the majority of folks with celiac disease, and both tests are widely available. Those who test positive for the first can then be tested for the second, but as Rick points out in the podcast, the definitive test is a biopsy of the lining of the small bowel. I would be sorely tempted if I tested positive for both tests, however, to try eliminating gluten from my diet and see what happened rather than undergo biopsy.

Other topics this week include the benefits of early follow up in avoiding rehospitalization in people with congestive heart failure in JAMA, a new type of stent for the heart in NEJM, and the risk of Alzheimer's disease in spouses who provide care for their affected spouse in the Journal of the American Geriatrics Society. Until next week, y'all live well. And please watch the YouTube!

Driving Miss Daisy

2010-05-03T09:10:00.000-07:00

Older drivers can imperil all of us as their driving skills decline, often so incrementally it may be unapparent until a problem occurs, and this risk increases if cognitive impairment is present. The Journal of the American Medical Association took a look at this issue this week, in an article directed toward physicians entitled 'The Older Driver With Cognitive Impairment."

The article reviews literature related to cognitive assessments, aging, driving outcomes, computer simulations and related matters from 1994 to 2009. It reveals that about 4% of drivers older than age 75 have some sort of a dementia, and that these folks largely continue to drive well into the disease process.

Computer simulated driving experiences consistently find that drivers with dementia are more likely to drive off the road, brake more slowly, make slower left hand turns, and apply less brake pressure in order to stop as compared to their counterparts without dementia. Overall, they are about twice as likely to have an accident.

While computer simulations are revealing deficiencies, the paper also reports that as far as road driving tests go, 88% of folks with very mild dementia and 69% of those with mild dementia were able to pass such an exam. The average time to driving cessation for those with very mild dementia was 2 years, with those with mild dementia giving up the keys after 1 year. The clear conclusion seems to be that many cognitively impaired drivers remain on the road and that methods for assessing them may be inadequate.

In order to get a good picture of how well someone is driving, a caregiver or family member can be questioned, and objective evidence such as scratches or dents on the car, tickets or being pulled over by a policeman, getting lost, especially on familiar routes, and having other drivers honking or worse gathered. This may provide a clearer idea of how someone is doing behind the wheel.

As Rick and I discuss in the podcast, driving cessation here in the US is problematic at best. Our public transportation options are mostly limited, and cars are such a symbol of personal freedom and self-determination. This article suggests physicians step into the fray and begin such discussions with their patients early, to give them plenty of time to plan alternative transportation, and that they emphasize the need for personal and public safety.

Other topics this week include the benefits of sigmoidoscopy in reducing colon cancer deaths in the Lancet, deep brain stimulation for those with advanced Parkinson's disease in Lancet Neurology, and harm related to vitamin B supplementation in people with kidney disease related to diabetes in JAMA. Until next week, y'all live well.

Treating Head Lice

2010-04-26T07:01:00.000-07:00

In our very open society, few topics remain unmentionable. But bring up head lice and watch the room clear. The mere thought of creepy crawlies invading one's hair is enough to make most people squirm, and head lice also enjoy an association with uncleanliness and sub par personal hygiene. To make matters worse, the little beasties can be very difficult to eradicate. Kudos then, to the New England Journal of Medicine, for wading into this distasteful morass to offer help. Oral ivermectin versus malathion lotion for difficult to treat head lice examines the most effective way to get rid of the buggers when they are loath to go.

More than 800 children who had already failed treatment with an insecticide-containing shampoo were divided into two groups, one of which received an oral medication called ivermectin, while the other was treated with a shampoo containing an insecticide called malathion. Turns out the oral medication was better at eliminating the infestation than the shampoo. Better than 95% of those who received ivermectin were cured, while among those who used 0.5% malathion shampoo, 85 to about 89% responded. Looks like ivermectin is the superior choice.

Rick points out in the podcast, however, that simply switching wholesale to treatment with ivermectin is likely to result in more resistant organisms, so sticking with the original strategy of trying commonly available shampoos first is probably best for all concerned. Other things to keep in mind to improve one's chances of success include treatment of all household contacts simultaneously and washing all bedding and items that may have come in contact with an infested person's head in hot water.

A minimum of two treatments is required, whether topical or oral medications are used, and they must administered according to a strict timetable. That's because the first treatment kills the adult lice and the second the eggs, or nits, that are attached to the hair shaft. The second treatment is timed to coincide with emergence of the nits, and not treating accordingly is a common cause of treatment failure.

It's worth blowing a few urban myths out of the water here for parents of kids who come home with head lice. Personal hygiene is a non starter. Kids 3-11 and their families are most likely to become infected and that's because kids share hairbrushes, wear each other's hats and the like. It's much less likely to become infected from the back of a couch or a pillow where an infected person's head has been. So tell your kids that when it comes to hats and hairbrushes, sharing is not a good thing.

Other topics this week include coping with jet lag, also in NEJM, sudden cardiac death due to something called 'commotio cordis' in NEJM, and heat stroke and heat exhaustion in the Lancet. Until next week, y'all live well.

Fixing the Aorta

2010-04-14T05:21:00.000-07:00

The aorta is the body's biggest blood vessel. It arises from the heart, curves upward, then descends through the chest cavity, crossing the diaphragm into the abdomen, where it is referred to as the 'abdominal aorta.' And it is here that this giant and vital pipeline is most likely to develop a weakening or ballooning in its wall called an aneurysm. This condition is known as 'abdominal aortic aneurysm' or 'AAA' for those in the know.

AAA is an increasing problem, especially for older men. We could think of it as a success story since the majority of people have to live long enough to develop the condition, but the big danger is that the aneurysm will rupture, most likely resulting in sudden death. The US Surgeon General has recently mounted a public education campaign to focus awareness on AAA since cases are increasing in that fastest-growing segment of our population: those aged 80 and older.

What can be done about AAA? A study in this week's NEJM takes a look at two interventions: so-called open surgery, where a traditional operation to repair the ballooning part of the aorta is performed, and so-called endovascular repair, where an instrument is snaked up through the vessel and a graft is placed over the area that is weakened. The study concludes that while endovascular repair is less of a problem up front, it offers no benefits in terms of survival over the long haul compared with open surgery, and is more likely to require another operation down the road. It's also more expensive because the grafts are quite pricey. Rick and I both conclude in the podcast that if we were in the unenviable position of having to choose, we would pick the open repair.

Things can be done to minimize your chances of developing AAA. Don't smoke, keep your blood pressure under control, and watch both weight and diet. Just about the same advice for a long and healthy life in all ways. In the case of AAA though, you should also ask your physician about an ultrasound examination of your abdomen. If a ballooning area is found on your aorta, size matters. It's not necessary to intervene until and unless the area reaches a certain size. So don't be too concerned if you're told you have AAA but your physician chooses to simply watch it for a while.

Other topics this week include appropriate control of heart rate in a heart condition known as atrial fibrillation, also in NEJM, and two studies from JAMA: the impact of financial considerations in people seeking treatment for heart attack, and screening infants for a viral infection known as CMV. Until next week, y'all live well.

Complex Spine Surgery in Older Folks

2010-04-12T14:09:00.000-07:00

Should you have surgery on your lower, or lumbar spine? For many, if not most people, the accumulated evidence from several studies seems to conclude that a conservative intervention known as 'decompression' is okay, but the more complex procedure known as 'fusion' isn't very helpful and may actually be harmful in the long term. Now a study in JAMA demonstrates that among Medicare recipients, the rate of complicated fusion procedures on the lumbar spine has increased by a factor of 15.

That's right, there are 15 times more complex surgeries taking place in the 2002-2007 period than took place before, while the actual number of surgeries for low back problems declined as did the more simple decompression or simple fusion. And the news gets worse as other measures such as 30 day mortality or major complications were also increased in those who underwent the complex fusion.

Yikes. What's going on here? How do we account for this dramatic increase in complex fusions in a vulnerable population of people? The authors very charitably suggest that surgeons may believe that a single, more complex operation will reduce the likelihood that the person will need another operation later on, and are persuaded that newer prosthetic devices, better anesthesia and the like will offset the risks of the more dramatic operation.

The authors also state, however, that their study suggests that use of the most conservative approach that can relieve pain should be the objective. Rick and I suggest in the podcast that patients need to very carefully weigh their options when it comes to spine surgery, and most definitely get more than one and perhaps more than two opinions on the best way to manage lumbar back issues. Long term studies on back interventions have shown that when outcomes are examined five years later, they're often the same for surgical versus nonsurgical approaches, which can include physical therapy, weight loss pain medications and others.

Other topics in this week's podcast include mothers and their believes about infant sleeping positions in this issue of Archives of Pediatric and Adolescent Medicine, overcoming the obesity gene with exercise in the same journal, and lung function in folks involved in 9/11 rescue efforts in NEJM. Until next week, y'all live well.

Calculations for the Perfect Spouse

2010-04-05T05:55:00.000-07:00

While various statistics are bandied about related to one's risk of divorce, most of us can agree that chances are almost even that following marriage, divorce is a likely outcome. Just in time for April Fool's Day 2010, the European Journal of Operational Research has provided us with a mathematical model whereby societally, we can minimize said likelihood: Optimizing the marriage market: an application of the linear assignment model. (vol. 202, issue 2, 16 April 2010, pgs 547-553).

The study looked at almost 1100 couples aged 19 (!) to 75 years and examined which factors were most important to a long and happy relationship. (I'm still wondering, for the record, how a 19 year old could have a long marriage?) First of all, the researchers concluded that wives should be about five years younger than their spouses. A shared heritage was also important. It was preferable that women were at least 27% more intelligent than their men, and that she held a degree while he did not.

No surprise here: if you're planning to marry someone who's already been divorced, your odds are greater that your union too, will end in divorce. This factor is mitigated somewhat if both partners have been previously divorced. Now here's what the authors suggest for these Swiss citizens: reallocation of 7 of 10 spouses to a more mathematically optimized spouse based on the factors identified.

How about it? Would you be willing to give up your spouse for a state-identified partner with an eye toward preserving societal stability through long term marriages? Hmmmm. I bet that would be a tough sell even in forward-thinking Switzerland.

Other studies we cover in this week's podcast include the myth of knuckle-cracking and arthritis (crack away!), in Arthritis and Rheumatism, vol.41(5),May 1998, pgs.949-950, the safety of parachutes in the British Medical Journal, and placebos, extra-strength placebos and generic placebos in the Journal of Irreproducible Results. Laugh out loud, and until next week, y'all live well.

Severe Allergies in Kids

2010-03-28T03:41:00.000-07:00

High on the list of challenges related to parenting is managing the life of a child with severe food allergies. That's because the stakes are high: such children can experience the very extreme reaction to exposure to their allergen (that's the food to which they're allergic) by developing anaphylaxis. And in this issue of Pediatrics, we learn that one in eight children need not one, but two doses of a medication needed to interrupt anaphylaxis.

Anaphylaxis, of course, is medicalese for a constellation of symptoms that progresses past itching, hives and perhaps swelling of the tongue and face, to difficulty breathing, more swelling of throat and tongue, pallor, loss of consciousness, and death due to the child's inability to breath. Yikes.

Why does all this stuff happen? The allergen invokes a huge release of a body chemical called histamine. This in turn produces leakage of fluids into the tongue, throat and other vital passages for air, closing them off. Here's the bad news: such reactions are increasing as food allergies as well as other types of allergies are increasing dramatically. And this study shows some rather disturbing issues. The way to counteract the effects of histamine is to administer epinephrine, and when parents know their child has such a problem they keep a prefilled syringe on hand so they can give the drug when an emergency arises. Now we learn that a sizable percentage of kids need two doses, not one.

Other issues revealed by this study include the fact that when they were discharged from the hospital following their severe allergic reaction, only 43% of kids were prescribed epinephrine. And a paltry 22% were referred to an allergist. That's also problematic because there are treatments for food allergy, including incremental exposure to the food over time by an allergist to induce tolerance, which is potentially life saving. Yet if a child doesn't go to an allergist this strategy will not be employed. Rick and I conclude in the podcast that parents need to keep two doses of epinephrine on hand and ask for a referral for their child.

Topics we also discuss this week include exercise and avoiding weight gain in middle aged women in JAMA, the impact of one measure of kidney function in JAMA, and a heart hormone as an indicator of heart failure in Archives of Internal Medicine. Until next week, y'all live well.

Symptoms of Parkinson's Disease

2010-03-22T03:53:00.000-07:00

Most of us have seen someone with Parkinson's disease. Typically people with the disorder have a tremor in one hand or arm; the appendage often seems to be moving with a mind of its own. Sometimes facial muscles may seem rigid or those with Parkinson's may have a lot of trouble initiating walking. And the disorder is very common, affecting about 1 million people in the US alone, with perhaps 4 million worldwide. More men than women develop Parkinson's.

Turns out that while the muscle effects, or so called 'motor symptoms' of Parkinson's disease are very troublesome, most people with the disorder are more bothered by the other constellation of accompanying problems, or so called 'nonmotor' symptoms. Treatment of nonmotor symptoms of Parkinson's disease in this issue of Neurology chronicles these and discusses their management.

High on the list for men with the disorder is erectile dysfunction, and this can be managed effectively for many with sildenafil or its cousins. For people who have trouble sleeping use of levodopa/carbodopa seems to help. This may make sense since Parkinson's disease arises because of the destruction of nerve cells or neurons that produce a chemical to help nerve cells communicate called dopamine. These drugs may also help with restless legs syndrome or RLS, where an irresistible urge to move one's legs while trying to sleep is also problematic and may affect those with Parkinson's disease. Some report that use of the supplement melatonin aids in the sleep issue.

The review concludes that for many of the other problems people with Parkinson's report, including depression, excessive daytime sleepiness, and low blood pressure when rising from a reclining position, known in medicalese as 'orthostatic hypotension' there is insufficient evidence to recommend a specific treatment but clinicians might try a number of possibilities and see if they help. Rick and I agree that the review underscores the need for people with Parkinson's disease to express problems other than the muscle issues to their physician. Greater awareness of the range of troublesome conditions affecting folks with Parkinson's disease will lead to develop of more effective, evidence-based management strategies.

Other topics in this week's podcast include personal identification possible using bacteria on hands from the Proceedings of the National Academy of Sciences (PNAS), and neither tighter blood pressure or lipid control seem to help people with diabetes avoid complications of cardiovascular disease such as heart attacks or strokes (meeting brief to be published). Until next week, y'all live well.

Alcohol Consumption and Weight in Women

2010-03-14T11:50:00.000-07:00

Light to moderate consumption of alcohol seems to offer a range of health benefits, and now another one has been added to the list: women who consume alcohol lightly or moderately gain less weight than their teetotaling counterparts. That's in this week's Archives of Internal Medicine, Alcohol Consumption, Weight Gain and Risk of Becoming Overweight in Middle-aged and Older Women.

The study analyzed data from the Women's Health Study and included responses from almost 20,000 women. Women entering the study were free of cardiovascular disease, diabetes, or cancer and had a normal body mass index ranging from 18.5 (pretty skinny, in my estimation) to 25 (normal but a bit chunky). The women were followed for almost 13 years and alcohol consumption and a host of other factors were assessed annually during that time.

Here's what they found: women who consumed alcohol in the light to moderate range had a lower risk of becoming obese and did not gain as much weight as those who did not drink alcohol. This was quite a surprise because alcohol is, as the authors call it, a "nontrivial" source of calories and might be expected to contribute to weight gain over time.

Another curiosity is that previous studies haven't looked a normal weight individuals over time, they've been largely cross-sectional. These studies have been all over the map with regard to the association of alcohol consumption and weight in women, either appearing to result in weight loss, gain, or neither. Studies in men of the same ilk found either gain or no apparent effect on weight related to alcohol consumption.

The authors make the point that while men tend to drink alcohol in addition to their other calories, women tend to substitute alcohol for something else, and in this study consumed fewer carbohydrates. This may account for the lack of weight gain in comparison to previous studies in men. They also speculate that women may metabolize alcohol differently and that could also contribute.

Here's what I have to say: ladies, salute! (That would be the Italian phrase offered as a toast). It's great to know that something enjoyable also qualifies as healthy, and this observation underpins that old adage about everything in moderation. Rick says in the podcast, of course, that if you're not someone who enjoys alcohol or have never been much of a drinker, this isn't a reason to start. But for those of us, and I'm among them, who do consume alcohol in moderation, we can feel just fine about that.

Sex and healthy aging from the British Medical Journal also made the cut this week, as did Lancet's blood pressure fluctuations and stroke risk. Finally, we round out the podcast with NEJM's poor yield from coronary artery assessment in those without symptoms. Yet one more test to give a miss. Until next week, y'all live well.

Aspirin and the Prevention of Cardiovascular Disease

2010-03-08T08:11:00.000-08:00

Aspirin is an interesting medication, with a really fascinating history for the nerds among us. One of its big uses today is for so-called 'secondary prevention' of cardiovascular events, such as heart attacks or strokes. The prevention is secondary because aspirin is used after such an event has taken place, in order to keep a second event from happening. In a classic line of reasoning we see again and again, 'if some is good is more better?', this week's JAMA reports a study of aspirin for primary prevention, or before the first event takes place, to see if that, too, can be avoided.

Aspirin for Prevention of Cardiovascular Events in a General Population Screened for a Low Ankle Brachial Index took a look at close to 30,000 men and women aged 50 to 75 years living in Scotland. None of these folks had apparent cardiovascular disease, and all of them had an ankle brachial index, or ABI, screening.

Here's what happens in an ABI screening: blood pressure is taken in the arm and the leg, and a ratio is computed. Usually these blood pressures are similar, so the ratio would be high, but when the ratio is low it's an indicator of atherosclerosis. And as Rick points out in the podcast, people are more likely to develop atherosclerosis in the leg than in the arm. Those people with a low ratio were either given one 100 mg enteric coated aspirin daily, or a placebo. Then they were followed for about 8 years, and the number and type of cardiovascular events were recorded.

Disappointingly, cardiovascular events were not significantly reduced in those who took aspirin. What was increased among the group who took aspirin was the risk of a fatal bleed within the head. The likely conclusion then, is that for what appears to be a very small or nonexistent benefit, the risks are too great.

Big questions remain, of course. Why is aspirin clearly helpful in the secondary prevention capacity? I'm reminded of research in cancer genetics and natural history, which demonstrates that over time, different mutations are manifest that may enable the disease to spread and survive. Is it possible that atherosclerosis is similar in that the initial process that leads to the deposition within the arteries is one thing, while additional plaque formation is something else? And that perhaps the additional plaque formation can be ameliorated with aspirin but not the initiation? Only time, and more research (of course!) will tell.

Other topics this week include salt in our diets, screening athletes for cardiovascular problems, and treatment of blockages of the carotid arteries in The Lancet. Until next week, y'all live well.

Quinine and Muscle Cramps

2010-02-28T15:47:00.000-08:00

Leg muscle cramps, aka 'charlie horses' and painful contractions of skeletal muscles elsewhere in the body, are really not a lot of fun, striking mostly in the middle of the night, disrupting sleep and necessitating rather bizarre nocturnal gyrations to alleviate. As a very regular, and Rick might even say manic, exerciser, my own experience with these cramps is unfortunately extensive. I am not alone; a United Kingdom study of adult outpatients found that 50% reported cramps at least once per week, with the number of patients reporting them increasing with age.

Is there any relief for this type of muscle cramping? A review in this issue of Neurology takes an exhaustive look at many of the studies available and concludes that quinine isn't a good choice and moreover, is associated with a range of side effects, including death. Yikes. While I am usually averse to revelation of personal information, I feel obliged to admit that I do use quinine regularly for this purpose, although I take a very small dose, such as is found in a quart of diet tonic water. I'm happy to say it helps a lot in preventing these cramps. Yet the majority of pill forms of quinine have been unavailable in the US since 2006, when the FDA cited 665 adverse event reports and 93 deaths as compelling evidence to remove them from the market.

If not quinine, then what? The review also looks at various other drugs as well as supplements and vitamins. Here's what they conclude: a daily vitamin B complex including 30 mg per day of vitamin B6 helped almost 90% of patients, an agent called gabapentin helped some people, as did verapamil. Both are drugs you'll have to ask your physician about if you want to give them a try.

Things that didn't help: muscle stretching, hydration (operating on the idea that cramping is the result of dehydration, which often follows exercise), and a host of other drugs. The authors conclude that additional research is indeed indicated given that the condition is so common, a perennial favorite conclusion of mine. Other topics this week include the FDA report on Avandia and its implications, cognitive decline in elderly people following hospitalization, and the Institute of Medicine report on the sorry state of diagnosis and treatment of hypertension or high blood pressure in the US. Rick and I also have to say mea culpa; we erroneously reported the quinine study as the Lancet so we apologize. Until next week, y'all live well.

The Awesome Power of Placebos

2010-02-21T05:33:00.000-08:00

Placebos are a very curious subject. By definition these are sham pills, often called sugar pills, or treatments that are given in a study as comparators to the active drug or treatment. Sometimes disparaged as trickery, placebos are now earning a respected place among the medical cognoscenti. As witness to this, a review article in this week's Lancet, Biological, clinical, and ethical advances of placebo effects, concludes that placebos indeed can induce meaningful and helpful clinical effects, and that further research is needed to define how best to transparently harness these effects to the patient's benefit.

Well. Who knew that those inert sugar pills, simulated treatments, and other forms of quasi-medical quackery would legitimately earn the right to reside in the therapeutic armamentarium? (Apologies to nonmedical folks reading this; that's the constellation of remedies, medications and procedures that can be considered in the treatment of ailments).

The review article cites some very interesting observations made in studies. For example, when drugs given without the patient's knowledge by a computer pump are compared to those given by a physician, those given by the physician result in more therapeutic benefit. This would be the self-same medication at the same dose. Similarly, pain medications given by injection are rated as providing more pain relief than oral drugs. Same drug. Clearly something besides receptors or other bodily mechanisms is at work here.

The authors cite research identifying psychological factors such as expectation and/or desire for the relief of symptoms such as pain, and conditioning as important in allowing placebos to work, but also tantalizing findings related to pathways in the brain in additional to the well-known opioid receptors that seem to be activated.

Perhaps most interesting is the frontier of research into placebos and how to harness their power to improve treatments. Ethics must also be considered here; is it okay to treat a patient by tricking him or her into a certain belief, even if that belief triggers the desired end? Hmmmm. But as Rick points out in the podcast, the great thing about placebos is they're free of side effects.

Other topics this week include research into King Tut's pedigree in this week's JAMA, aspirin use and breast cancer recurrence prevention in this issue of the Journal of Clinical Oncology, and brain activity in those in a persistent vegetative state in NEJM. Until next week, y'all live well.

Treating Obese Teenagers

2010-02-14T09:57:00.000-08:00

Teenagers who are obese may now be able to elect a fairly safe and effective means of treating their weight problem: gastric banding. Reported in this week's Journal of the American Medical Association, Australian researchers used the laparoscopic technique in a group of teens whose body mass index exceeded 35. That's not just obese, it's very obese. When compared to teens with the same BMI who received diet and exercise interventions alone, the gastric banding group did much better in terms of overall weight loss and other measures, such as sleep apnea, diabetes or prediabetes.

Gastric banding involves restricting the size of the stomach with a banding device. The surgery itself is done laparascopically, with just a few small incisions. And the result is adjustable if needed down the road. This compares very favorably with gastric bypass, where substantial rerouting and organ removal is performed in a very significant surgery. Long term studies have demonstrated that while gastric bypass is usually very effective, it can result in malnutrition some time later.

A few of the teens who had gastric banding in this study required subsequent revisions, but there were no problems during the original surgery or in the first 30 days of follow-up. This illustrates a point Rick makes in the podcast: if you're considering gastric banding that old rule of surgery applies. Go to a center where both surgeon and staff could do these things in their sleep because they do them so frequently.

We conclude in the podcast, however, that it's an indictment of our society that we're having such a profound problem with teenage obesity. Data cited in this study indicate that over 5 million American teenagers today are obese, as defined by a BMI greater than 30. Obesity, of course, is not a condition that arises spontaneously overnight. Physicians and other health care professionals need to assess weight in children and teenagers regularly and intervene early to prevent excessive weight gain before it happens. And as a society we need to emphasize good health habits.

Another topic this week fits nicely: preventing childhood obesity in this issue of Pediatrics. It's so simple and requires assuring that children get 10 hours of sleep a night, eat most dinners at home with the family, and reduce TV watching. Other topics this week include the utility of MRI in planning breast cancer surgery from the Lancet, and the interference of one common antidepressant medication with tamoxifen for preventing breast cancer recurrence in the British Medical Journal. Give us a listen! Until next week, y'all live well.

Long Term Exercise Help

2010-02-08T11:14:00.000-08:00

Women who are more physically active in midlife survive better and longer in old age than their more sedentary counterparts, yet another analysis from that robust dataset, the Nurses Health Study, has concluded. That's in this issue of Archives of Internal Medicine, which Rick and I discuss in detail in the February 5 issue of the podcast.

Data was analyzed for almost 14, 000 nurses who had enrolled in 1985, and who had made it to age 70 or beyond at the 1995-2001 follow-up. Data collected at intake included all types of physical activity and this was graded as to its degree of strenuousness and regularity. A calculation known as 'metabolic equivalent task' or MET, was made for each activity. Surprise! Those women who engaged in more challenging physical activity on a regular basis experienced a reduced level of illness and disability as they aged.

The researchers defined 'successful aging' as being free of 10 chronic disease, no coronary artery bypass surgery, no cognitive impairment, no physical limitations and no mental health limitations. Pretty good. Stay healthy until you die.

This study clearly underscores the many, many benefits of exercise. For women earlier in life we also know these include higher quality sleep, reduced risk of osteoporosis, bone fracture, and hip replacements, and fewer and more manageable menopausal symptoms. Paying it forward really does work.

Other studies in this same issue of the journal highlight how helpful regular exercise is, even for those who are already institutionalized or bedridden. No excuses! These studies also include men as study subjects, so gender doesn't give anyone a pass. Until next week, y'all live well.

Treating Severe Childhood Diarrhea

2010-01-29T04:14:00.000-08:00

Diarrhea is not a topic most of us like to think about much, but this week's New England Journal of Medicine brings it to the front burner. That's because childhood diarrhea is a leading cause of death, yes, that's right, death, for millions of infants and children worldwide. Most of that diarrhea is caused by a virus known as a rotavirus, and the good news is, vaccines are effective at preventing it.

Effect of Rotavirus Vaccination on Death from Childhood Diarrhea in Mexico describes the utility of vaccination in preventing a significant number of deaths due to rotavirus caused diarrhea. Depending on the age of the children vaccinated, the death rate declined by about 40%. Effect of Human Rotavirus Vaccine on Severe Diarrhea in African Infants showed that severe diarrhea and death was reduced about 55% in children who received two or three doses of the vaccine.

This is great news, right? Let's just ship out lots of vaccine to these countries and prevent a leading cause of child mortality. Well, as William Shakespeare and Rick intone, here's the rub: there are serious challenges to the distribution of the vaccine to the hinterlands. Once reconstituted, the vaccine must be refrigerated, and that's almost impossible in many parts of the world. But perhaps the biggest issue, and this is an indictment of Western society, is the money.

Turns out that here in the US, vaccination costs about $75 to $100. For much of the developing world, that may as well be $1 million dollars, since such a sum may comprise the family's budget for months. Right now, manufacturers are providing the vaccine at a very reduced cost, just pennies per dose in fact, but that's a limited time offer. Soon this lifesaving preventative will be beyond the reach of those who need it desperately.

Such stories give us pause as we argue and labor over reform of our healthcare system (such as it is) domestically. Seems like we should be able to earmark dollars for prevention, clearly the best strategy for virtually all health conditions, and especially for the young worldwide.

Other topics this week include how to use antibiotics in adults in the ICU in this week's Lancet, use of steroids and insulin in ICU patients in JAMA, and also in JAMA, the best way to treat that common heart condition, atrial fibrillation. Here's the link to the podcast:http://www.hopkinsmedicine.org/mediaII/podcastsinstructions.html. Until next week, y'all live well.

Aging and Fish Oil

2010-01-24T09:38:00.006-08:00

Oils from fish have been touted for years as elixirs of health; think cod liver oil in Victorian novels. More recently, fish oil, and specifically omega-3 fatty acids, have contributed to the demise of legions of cold-water fish. Now a study in JAMA, Association of Marine Omega-3 Fatty Acid Levels With Telomeric Aging in Patients With Coronary Heart Disease, is likely to accelerate the carnage.

This study is a fascinating demonstration of 'bench to bedside' medicine, something embraced at Johns Hopkins. Telomeres are the ends of chromosomes, presumably there to protect the actual business DNA of the cell each time it divides. It's been known for some time that as cells divide over the course of the lifetime of an organism, the telomeres get shorter. Nobel laureate Carol Greider, a member of the faculty at Johns Hopkins, was cited for her work on telomerase, an enzyme that is involved with preservation of telomeres.

Now it turns out that fish oils help preserve telomere length. The authors of this study thought that might be the case and developed the hypothesis that telomere preservation may account for the protective effects of fish oils in patients with cardiovascular disease. They looked at levels of omega-3 fatty acids in over 600 patients with known coronary artery disease and measured blood levels of the two primary omega-3 fatty acids, and assessed telomere length over a five year period. They found that those participants with the highest levels of the omega-3s had the longest telomeres.

Another interesting finding was that those who had the longest telomeres at the beginning of the study experienced the greatest benefit from omega-3s in terms of preservation. What this suggests to me is that it's good to start early in terms of fish oil consumption.

Lots of questions remain, of course, especially the supplement versus dietary consumption of fatty acids, but the impact of telomere length on aging and disease is something we expect to hear more and more about.

Other topics this week include obesity rates and obesity in children in this week's JAMA, risks of opioid medications in people taking them for chronic pain in Annals of Internal Medicine, and the risk of sudden death and occasional use of cocaine in the European Heart Journal. Please listen at http://www.hopkinsmedicine.org/mediaII/Podcasts.html. Until next week, y'all live well.

Aging and Fish

2010-01-24T09:38:00.005-08:00

Aging and Fish

2010-01-24T09:38:00.003-08:00

Aging and Fish

2010-01-24T09:38:00.001-08:00

Hormesis?

2010-01-17T07:38:00.000-08:00

Hormesis and Egyptians

What do you think of when you hear the term 'hormesis?' Rick and I both learned this week in the journal Analytical Chemistry, admittedly a bit of a stretch for us, that hormesis refers to the property of something having a beneficial effect at one level but a deleterious one at another. And we learned this from a fascinating study: Finding Out Egyptian Gods’ Secret Using Analytical Chemistry: Biomedical Properties of Egyptian Black Makeup Revealed by Amperometry at Single Cells.

Turns out that kohl makeup, that black eyeliner used by ancient Egyptian men and women to outline their entire eye, has a medicinal property. It leaches at very low levels into the fluid that bathes the eye continuously, creating a very low level of inflammation. This inflammation in turn helps protect the eye from conjunctivitis due to infections the Egyptians were susceptible to following periodic flooding of the Nile river.

Wow. Who knew? And the ancients were even more sophisticated than that. These lead compounds used in their eye makeup were not naturally occurring. Instead they required fairly skilled chemistry to produce so that the lead level that leached from them was just right to elicit a helpful immune response. Another Egyptian wonder, right alongside the pyramids.

The study illustrates this term we're likely to hear more and more: hormesis. Rick says there are many examples of this in medicine today: low levels of many vitamins turn out to be helpful in some people, especially those who are vitamin deficient, while higher levels aren't at all helpful and may be harmful. Witness vitamin E supplementation in smokers.

Alcohol consumption is another great example. For many people a low daily consumption of alcohol seems to have a positive impact on health but the perils of overconsumption are well-known. Even exercise can be thought of 'hormetically' if such an adjective exists, where some or moderate exercise daily helps, but too much leads to overuse injuries and worse.

Other topics this week include whether chronic infections can cause in increased risk of stroke in this issue of Archives of Neurology, and a failure to treat chronic tendon problems and a mammography guideline update in this week's Journal of the American Medical Association. For a full discussion listen to our podcast: http://www.hopkinsmedicine.org/mediaII/Podcasts.html. Until next week, y'all live well.

Antidepressants and Depression Severity

2010-01-10T12:51:00.000-08:00

Only Most Depressed Benefit From Antidepressants

Books such as 'Prozac Nation' bear witness to the fact that antidepressant medications are among the most widely prescribed and taken drugs in the United States, and worldwide. Now a meta-analysis published in this week's JAMA raises the question of who really benefits from such medications.

Antidepressant Drug Effects and Depression Severity pooled data from 6 studies and included 718 adult patients. Information on depression severity was gleaned using the Hamilton Depression Rating Scale, a more quantitative, objective measure of how badly someone is affected by their depression than either reports by the patient or clinical impressions. The researchers found that the people who received the most benefit from antidepressant medications were those who were more depressed to begin with. Those with only mild or moderate depression didn't gain the same relief or any relief at all. It therefore appears that only those with severe depression should really use these drugs.

Rick and I discuss in the podcast the fact that the majority of people with depression fall into the mild or moderate category, so millions of folks who take antidepressant medications are unlikely to benefit from them. Since these drugs, like all drugs, have a host of side effects, it appears that some reanalysis is in order.

How can such a situation develop? Rick explains that when clinical trials are done the most severely affected patients are recruited for study, since presumably the drugs will show a benefit in those who are the sickest if a benefit is seen at all. Yet studies haven't been done to establish efficacy in those with less severe depression, and now it seems there isn't a benefit.

Does this mean that the legions of people with mild to moderate depression are out of luck with regard to therapy? No, but instead of antidepressant medications they could choose to undergo treatments such as cognitive behavioral therapy, which has been shown to be effective in this population. And then they could avoid things like sexual dysfunction that are also known to occur with the most commonly prescribed medications for depression.

Other topics this week include strategies to reduce surgical site infections in NEJM, the relationship between cigarette smoking and type 2 diabetes in Annals of Internal Medicine, and changes in the adult immunization schedule in the same journal. Until next week, y'all live well.

Blood Clots and Surgery

2010-01-03T04:49:00.000-08:00

Clotting Risk Higher, Persists Longer Than Anyone Knew

It's no surprise to anyone that blood clots form more commonly following surgery, and plenty of strategies are in place to make sure they don't. Medicalese for this is venous thromboembolism or VTE, with two forms, DVT or deep vein thrombosis, and PE or pulmonary embolism, the usual suspects. But now a huge study in the British Medical Journal has shown that the risk of blood clot formation is much higher and lasts longer than was previously suspected: Duration and Magnitude of the Postoperative Risk of Venous Thromboembolism in Middle Aged Women: Prospective Cohort Study.

First of all, this study is astonishing because it is part of the 'Million Women Study,' an effort by the British national health service to collect health data on just about a million women with an average of of 55. Clearly, such a gigantic collection of statistics has a lot of power to discern trends, and that's just what happened here.

Researchers examined records of women having surgery and then looked at whether VTE occurred and when. What they found is that women were almost 70 times more likely to require hospitalization for VTE following inpatient surgery, and even outpatient surgery increased risk by a factor of 10. Risks were further stratified based on what type of surgery took place. Women who had hip or knee replacements were almost 220 times more likely to suffer a clot than women who hadn't had surgery, and this risk was highest during the three weeks following surgery but was still increased 12 weeks postoperatively.

This is huge for many reasons. Most methods for decreasing the risk of blood clots, such as use of compression stockings and medications, are used while people are still in the hospital, but this study shows the risk remains high when discharge is almost certain to have taken place. As Rick points out, these observations argue for longer use of anticlotting medications, but that comes with risk, too.

What's needed are more studies to determine what the best duration of anticlotting medications and other strategies is, and whether newer drugs such as clopidogrel and dabigatran would be helpful. For now, people who've had surgery, and especially those who've had knee or hip replacements, need to be aware of symptoms they may develop that would point to the formation of a blood clot.

Symptoms of clot formation would depend on where the clot formed but could include excessive swelling of the legs, especially one or the other, excessive fatigue, or pain in the legs or chest. If you've had surgery recently and develop such problems seek immediate medical attention.

Other topics this week include transmission of the flu among those who live in the same house in NEJM, more autism than we thought in Morbidity and Mortality Weekly Report, and a lack of benefit to telemedicine in the ICU in JAMA. Until next week, y'all live well.

Is Santa a Bad Influence on Public Health?

2009-12-28T09:40:00.001-08:00

Overweight, Sedentary, and Suffering Sleep Deprivation

Santa embodies a plethora of poor choices when it comes to health, an article entitled "Santa Claus: a public health pariah?" in the most recent issue of the British Medical Journal asserts. In view of the fact that Santa is more recognized than that other icon of popular culture, Ronald McDonald, and may also leverage his considerable notoriety toward the furtherance of public good, Rick and I agree that Santa should change some aspects of his gig. In keeping with the season, we focus our attention on this problem in this week's podcast.

One of the first things Santa can do is forgo cookies and milk, and in some parts of the world, mince pies and sherry, at every stop. Instead he could elect to consume the celery sticks and carrots traditionally left for Rudolph. This would also allow him to avoid the accusation that he is driving while drunk, clearly a habit we don't want our children to adopt. If keeping up his energy is a problem, Rick suggests that Santa could consume that favorite of nonperishable foods, fruitcake.

Santa should also consider a more active role in toy production and delivery. Currently elves are engaged full time in toy production and it's unclear what Santa is doing much of the time. We do see him engaged in very sedentary activity sitting on thrones in shopping malls worldwide following Thanksgiving until Christmas Eve, then finally, relying on a sleigh and eight tiny reindeer to distribute gifts. We think a bicycle or running would be a more heart-healthy choice.

We worry that Santa's girth speaks to high risk for cardiovascular disease, high blood pressure and diabetes. Of course he has been around for quite some time so he must have good genes, but even those who've chosen their parents carefully can only avoid the consequences of high sugar consumption, belly fat and sleep deprivation for so long.

Other good public health messages would be conveyed if Santa would use a seat belt and wear a helmet when he's roof surfing. For more suggestions for Santa and anyone else trying to avoid the perils of the holidays, please listen to our podcast. And to all, a healthy and happy 2010. Y'all live well.

Benefits to Tight Blood Glucose Control?

2009-12-20T04:40:00.000-08:00

Keeping Blood Sugar Low May Not Help

In a classic 'if a little is good, more is better' manner, the medical establishment has for years touted tight blood sugar, or glucose, control as the best means of avoiding the complications of diabetes. Surprise! Now it's turning out that like so many areas of medicine, this one size fits all approach doesn't work. A study in this issue of Annals of Internal Medicine, Comorbidity Affects the Relationship Between Glycemic Control and Cardiovascular Outcomes in Diabetes, concludes that whether tight glucose control is effective or not depends on the presence of other health issues, so-called 'comorbidities.'

Let's talk about 'comorbidities' first. This is medicalese for the constellation of health problems or conditions in a single individual. As everyone knows, those who develop type 2 diabetes often are overweight or obese, may also have high blood pressure, existing heart disease, or almost any other compromising health condition. When tight blood glucose control is imposed on this background, it doesn't work as well, and in fact may actually compromise overall health, as has been shown in previous studies.

What defines tight blood glucose control? The standard for assessing this is hemoglobin A1c, often abbreviated HbA1c. What is being measured here is how many sugar molecules are attached to hemoglobin, the oxygen carrying compound in red blood cells. When blood sugar is high, some of these sugar molecules become attached to this compound, and since red blood cells are in circulation for a couple of months, this measurement provides an average of how high the blood sugar has been during that time period.

Many diabetes experts aim for an HbA1c measurement of 6.5 or so. But this study demonstrates that for those with other conditions, such a goal doesn't reduce cardiovascular complications in those with comorbidities, suggesting that more modest goals may be more appropriate in people who are already dealing with a host of health issues.

Rick and I both seize this opportunity in the podcast to reiterate once again that old public health message that by far the easiest course is prevention. In terms of diabetes, heart disease, high blood pressure and obesity, exercise, weight control, and a good diet will help most people avoid developing these conditions in the first place.

Other topics this week include asthma and COPD and a genetic mutation in this week's NEJM, cancer and CT scans in Archives of Internal Medicine, and two studies on Alzheimer's disease in this issue of JAMA. Until next week, y'all live well.

Oxygen and Headaches

2009-12-13T05:08:00.000-08:00

Severe Headache May be Treated With Oxygen

Headaches seem to be a common human condition, with almost everyone having suffered one at some point in life. In the spectrum of headaches, the most severe form is known as 'cluster' headaches. Clusters are characterized by excruciating pain behind or around one eye, tearing, drooping of the eyelid, runny nose and other symptoms. More men than women get them, with women who do describing the pain as "worse than childbirth." No surprise, then, that cluster headaches are one cause of suicide.

Yikes. Now there's good news with a study in this week's Journal of the American Medical Association: High-Flow Oxygen for Treatment of Cluster Headache. In 109 patients with cluster headaches, use of 100% oxygen delivered by face mask relieved the pain in almost 80%. In a very revelatory study design, participants who received oxygen also tried just room air delivered through a face mask, and only 20% responded. Clearly then, oxygen is important, and this makes sense in light of what we do know about headaches: blood vessels seem to constrict and relax and blood flow is compromised when a headache occurs. Since blood is delivering oxygen, perhaps that's the key.

Other really great aspects to this study include the fact that oxygen is non-toxic in this setting and doesn't have side effects, unless as Rick quips in the podcast, you are a smoker and you try to use your oxygen while you're smoking. Oxygen can be self-administered, in contrast to sumatriptan, one drug known to be effective but which must be injected. All around, a win-win for those who are unfortunate enough to have cluster headaches.

Now that this study has shown oxygen's benefit in cluster headache, the way is paved to try it in much more common migraine headaches as well. Here we also known that some blood vessel component is important so it may help. Stay tuned for studies addressing the use of oxygen in this much larger population of those who get bad headaches.

Other topics in this week's podcast include soy consumption and breast cancer survival, also in this week's JAMA, a new type of anticlotting medication in this week's NEJM, and in this issue of Archives of Pediatric and Adolescent Medicine, more evidence to support placing infants to sleep on their backs to avoid SIDS. Until next week, y'all live well.

Hope for an HIV Vaccine?

2009-12-06T04:07:00.000-08:00

HIV Vaccine Provides Modest Benefit

The quest for an effective vaccine against HIV resembles a search for the Holy Grail. That's what I quip on this week's podcast, and while the phrase is tired and shopworn, in this case it fits. We've known about the cause of AIDS for decades now, the virus continues to kill tens of thousands annually, and although we have very effective drugs that keep the virus in check they are too expensive to offer much solace to much of the world's HIV infected population. In this week's NEJM, a glimmer of hope is reported: Vaccination With ALVAC and AIDVAC to Prevent HIV-1 Infection in Thailand.

Thailand is a country with a large population of both HIV infected people and those at risk for contracting the virus. Investigators evaluated over 16,000 volunteers who received multiple injections of the vaccine. Each volunteer was monitored for whether they became infected with HIV at the end of the six month vaccination series, and again at six month intervals for three years.

A couple of things are worth mentioning about the study subjects: they were not infected with HIV at the beginning of the study but were at risk for infection, either because they were sexual partners with someone who was already infected, they used IV drugs, shared needles, frequented commercial sex workers and the like. Subjects were categorized for whether they were at low, moderate or high risk for contracting the infection, and they were largely heterosexual.

At the end of the study, the vaccine was about 30% effective in preventing infection with HIV, depending on how the analysis was done. While this is not a great result, it's the best we have so far and the study tells us some very important things. First of all, traditional measures of vaccine efficacy don't apply in this case. Vaccination didn't impact on how many viruses were found circulating in the blood of those who subsequently became infected, nor did it have any effect on CD4 cells, the critical immune cell depleted by HIV. We also learned that multiple vaccinations were required. But it is a positive step and that's worth celebrating.

It's also important to mention that this study didn't go forward the way most do in that volunteers were not recruited, given the vaccine and then deliberately exposed to HIV, the way we assess many other vaccines. Clearly such a protocol would be unethical.

Other podcast topics this week include use of left ventricular assist devices in folks with heart failure, also in NEJM, aspirin use in those with stomach ulcers and consideration of a new bug in sore throats in young adults in Annals of Internal Medicine. Until next week, y'all live well.

Medications on the Fly

2009-11-29T08:40:00.000-08:00

Should IV Drugs be Given During Out-of-Hospital Cardiac Arrest?

For many years folks who study survival related to heart attacks experienced out of the hospital have lobbied for allowing emergency medical technicians (EMTs) to administer a range of drugs as well as other interventions. The clear goal is to improve a person's chances of making it to the hospital alive, where hopefully treatment will result in long term survival. Now a study done in Norway seems to conclude that use of the most common medication, epinephrine, does not result in any benefit to these folks and may actually result in harm. That's in this week's Journal of the American Medical Association: Intravenous Drug Administration During Out-of-Hospital Cardiac Arrest.

This study could only have been done in a country other than the US (that would be Norway), since about half of the study subjects (a total of 851) were given advanced cardiac life support only and the other half given life support plus intravenous drug administration. As Rick says, in this country IV drug administration is dogma, and a failure to use it heresy, in spite of the fact that no direct evidence of the benefits of epinephrine use in this context exists.

The study found that while slightly more people made it to the hospital alive when IV medication was used there was no statistically significant difference between the two groups related to hospital discharge, quality of CPR, or long term survival. The authors conclude, and Rick agrees, that larger studies examining this issue need to be conducted and perhaps some modification of resuscitation guidelines is in order.

Two things emerge from this study that are worth noting: one is the wholesale adoption and institution of a practice, that is, establishment of an IV line and use of epinephrine in those who've suffered cardiac arrest outside the hospital, in the total absence of any data examining this specific issue but rather extrapolations from animal models and other circumstances where a benefit was perceived. At best, rather contrary to our current climate of 'evidence based' medicine.

The other is the ongoing debate about best practices related to resuscitation efforts. Should CPR be done on the chest or the back? Are ventilations (breaths) even necessary? What is the optimal timing for chest compressions? How long should the practice be continued until emergency personnel arrive? What about use of automated external defibrillators?

Perhaps the most compelling reason the debate is so fierce is that heart disease remains the 8000 pound gorilla when it comes to causes of death, killing almost half a million people in 2005, according to American Heart Association statistics. That's a lot of people. By and large, many if not most of these deaths could be avoided if people would never start smoking or quit if they do so currently, watch their weight and diet, and exercise regularly. High blood pressure should be controlled, and those with a family history of cardiac problems perhaps elect other interventions as well. Until then, relying on changes in treatment or management guidelines is a BandAid approach.

Other topics this week include the change in cervical cancer screening guidelines issued by the American College of Obstetricians and Gynecologists, pain and falls in the elderly and no volume benefit seen with angioplasty in this week's JAMA. Until next week, y'all live well.

Breast Cancer Screening Guidelines

2009-11-22T04:41:00.000-08:00

Reduced Need for Mammography

Unless you've been living under a slimy rock this week, you know that the US Preventive Services Task Force has changed the screening guidelines for breast cancer. Instead of annual mammograms for all women over the age of 40, the guidelines are now tailored to reflect when the risk for developing breast cancer increases, and that's largely after menopause. Incidentally, right when the risk for the real killer in the room, heart disease, also rises. Here's the link to the recommendations, published in Annals of Internal Medicine: Screening for Breast Cancer: US Preventive Services Task Force Recommendation Statement.

The buzz over this change has been astonishing. The most pejorative comments seem to be coming from women concerned about a reduction in services at a moment when the nation is closely examining the spectrum of healthcare costs and seeking ways to reduce them. The outcry is fraught with allegations that women are once again being relegated to second class citizenry, with improvement in the nation's healthcare budget coming at the price of breast health. Really. Here's a novel idea: let's examine the data.

The data analysis shows that the number of screening mammograms needed to extend one woman's life relative to breast cancer in those aged 40 to 49 is 1904. That's a lot of screening, and as we're now seeing that radiation itself related to mammography may be harmful since its effects are cumulative, that's also a lot of potential damage. Add to that the psychological impact of being told you have a lump in your breast, the need for biopsy and perhaps lumpectomy, and the risk/benefit ratio tips clearly in the direction of reduced screening.

What about breast self-examination? The task force also found that there's insufficient evidence to support continued endorsement of this practice. But clearly, women are free to examine their breasts and report suspicious findings to their healthcare provider. No harm there.

Finally, the furor has been so overwhelming that for now, federal agencies that pay for routine annual mammography have stated that they will continue to do so. Since private insurers largely follow their lead, women who feel strongly about continued annual mammography are free to do so.

Interestingly, another issue critical to women's health we didn't talk about this week in the podcast is the change in recommendations for cervical cancer screening. Once again, data driven and based on research related to risks and benefits. And just to give fair play to the guys, the PSA/prostate cancer controversy also rages on, with Rick having stated that he hasn't had PSA screening and doesn't intend to anytime in the near future.

Other topics this week include whether more of a statin or the supplement niacin is best to reduce cholesterol from the American Heart Association meeting, published online in NEJM, dangers of drugs to stimulate red blood cell production in NEJM, and the relationship between cancer and vitamin B12 and folate supplements in JAMA. Until next week, y'all live well.

Statins and Gallstones

2009-11-16T09:10:00.000-08:00

Will Statins Soon be Added to Municipal Water Supplies?

Yet another benefit has been added to the list related to the use of statins - those medications intended primarily to reduce cholesterol in the blood. Why reduce cholesterol? Because high cholesterol is associated with a host of nasty consequences: narrowing or blockage of blood vessels and subsequent clot formation, heart attacks or strokes among them. Now what else is good about statin use? Turns out long term use of statins results in fewer folks forming gallstones and requiring surgical removal of their gall bladder. That's in the current issue of JAMA: Statin Use and Risk of Gallstone Disease Followed by Cholecystectomy.

Researchers in England, where they are famous for collecting health data on people as part of their national health service and doing studies on it, looked at over 27,000 people who had had their gallbladder removed (a cholecystectomy in medical jargon) and compared them on a number of variables to over 106,000 people who had not. Thousands in both groups had been taking statins.

The conclusion was that people who had taken statins for a couple of years had a reduced risk of forming gallstones that eventually required gallbladder removal. This is good news all around since cholecystectomy, while most often done laparoscopically where only small incisions are required, is still surgery with its consequent risks. From a public health perspective avoiding this operation results in huge savings to our health care system.

The study also accounted for other factors related to the formation of gallstones: female gender, obesity, high-carbohydrate and high-fat diet, and use of estrogen-containing contraceptives among them. Even when these factors were taken into account the benefit of statins remained. And as Rick quipped at the beginning of the podcast, it sure seems like statins have such a multitude of benefits we may one day supplement water supplies with them, much as we do with fluoride to prevent cavities in teeth.

But there are caveats to statin use: some people complain of muscle aches and pains, and a very small percentage will experience a compromise of liver function and need to stop taking them. So for now, taking statins if you have high cholesterol in your blood or if you are about to undergo certain types of surgery may help, but avoiding gallstones should not be your primary objective.

Other topics in this week's podcast include having your blood tested for lipids may not require fasting (!) in this week's JAMA, mood improvement on a low fat diet in Archives of Internal Medicine, and treatment of blockages in the arteries to the kidneys in NEJM. Until next week, y'all live well.

Which Bypass Surgery is Best

2009-11-08T04:29:00.000-08:00

The Final Word on Bypass Surgery?

Coronary artery bypass surgery, abbreviated CABG and pronounced like the vegetable, is necessary when someone's coronary arteries, those that supply the heart muscle itself with blood, become so extensively blocked that they must be replaced. The traditional way to do this is to crack open the patient's chest, harvest blood vessels from elsewhere in the body (yet another controversy we'll leave alone for today) and stitch them into place on the heart, thereby bypassing the blocked vessels.

Also traditional in this operation is stopping the person's heart. A dandy machine we'll call a heart lung bypass machine circulates the blood and provides oxygen to it while the heart is stopped. Once the new vessels are in place the heart is restarted, and voila! It now has enough blood to do its work. So what is the problem?

Lots of folks have complained that following this big operation, they had trouble thinking and remembering. The speculation was that stopping the heart was the cause, so a new operation was developed where the heart was left beating. A nimble surgeon stitched the new vessels into place on this moving target. But alas, problems existed with this operation as well, and now a big study in the New England Journal of Medicine has compared the two: On Pump Versus Off Pump Coronary Artery Bypass Surgery.

Over 2200 people were randomized, which means assigned to one group or the other essentially by a flip of a coin, to either on pump or off pump surgery. They were assessed at 30 days and again at a year, and the take home message is this: those who underwent the traditional surgery where their heart was stopped did better. There was no discernible difference between the two groups in thinking, or cognition, but those who had on pump surgery had a better blood supply to their heart and other superior outcomes.

Rick gives kudos to the VA Medical System for doing this study and adds the following caveats: choose a facility and a surgeon with experience. We reiterate this point again and again in the podcast but it bears repeating: experience matters greatly when it comes to better outcomes in the majority of interventions.

Other topics this week include the best way to quit smoking in the Archives of General Psychiatry, which doctors are overusing Pap smears in Annals of Internal Medicine, and the best mask for preventing transmission of the influenza virus in JAMA. Until next week, y'all live well.

Aging and Cardiovascular Fitness

2009-11-02T08:46:00.000-08:00

Cardiorespiratory Fitness Declines With Age, No Matter What

Here's the bad news: no matter what you do, what exercise regimen you adopt, how carefully you eat, the capacity of your heart and lungs, so-called cardiorespiratory fitness, will decline as you age. And the point of no return, when the decline happens much more sharply, is 45 years of age. That's in this issue of Archives of Internal Medicine: Role of Lifestyle and Aging on the Longitudinal Change in Cardiorespiratory Fitness.

We already knew that cardiovascular capacity diminished over time, with one very noteworthy study of male marathon runners demonstrating this fact with astonishing clarity. Now these researchers have examined data from almost 20,000 men and women (almost 35oo women!) enrolled in the Aerobics Center Longitudinal Study, including treadmill test results and data from comprehensive medical examinations. Study participants ranged in age from 20 to 96 years.

Results indicate that age 45 is the point of no return (shoot me now). That's when the rate of decline accelerates. Cofactors that make the decline even more precipitous include those well-known demons : smoking, obesity, and a sedentary lifestyle. People who did not smoke, didn't have a body mass index (BMI) greater than 25 and who exercised fairly strenuously on a regular basis preserved their cardiorespiratory fitness best. Clearly, the results indicate once again that you are in charge of your own health, and that choices you make will absolutely determine how well you age.

This last is also important from a societal perspective. People aged 80 and older comprise the fastest growing segment of our population, and we are all vested in how well they age, and how to keep them well until the end of life. The current healthcare debate has brought to the fore the fact that the biggest Medicare expenditures occur in the last six months of life. A generally healthier older population would likely reduce this outlay. Finally, more efforts need to be targeted toward prevention of obesity and smoking as well as adoption of a more active lifestyle in younger folks.

Other topics this week include risks related to use of so-called 'atypical antipsychotic' medications in children in JAMA, staving off type 2 diabetes in the Lancet, and the best insulin regimen for managing diabetes in NEJM. Until next week, y'all live well.

Erectile Dysfunction

2009-10-26T03:47:00.000-07:00

ED Can be Managed in Primary Care

Men with erectile dysfunction, (ED), known also as impotence, don't need to undergo lots of evaluation or testing to identify a specific cause, they can simply be given a trial of a class of medications known as PDE5 inhibitors, the American College of Physicians has stated. That's according to a review of many studies published on the subject and analyzed by the college in this issue of Annals of Internal Medicine: Hormonal Testing and Pharmacologic Treatment of Erectile Dysfunction: A Clinical Practice Guideline From the American College of Physicians.

ED is already an extremely common condition and affects men of all ages. For many the condition is transient, but for those in whom it persists for longer than three months, the college states that some intervention is appropriate. Moreover, projections indicate that rates of ED are likely to increase dramatically as a result of aging and diseases like diabetes and cardiovascular compromise, so effective management is important.

PDE5 inhibitors include drugs like sildenafil, vardenafil, tadalafil, mirodenafil, and udenafil. They specifically inhibit an enzyme known as phosphodiesterase 5, and by inhibiting this enzyme, allow an erection to persist. The majority of men in whom these medications are tried respond well, with few side effects, although more than 10% report headache. Other fairly common side effects include dizziness, flushing, and upset stomach.

One of the most important aspects of the college's clinical guidelines is the recommendation that ED can be managed by primary care docs and doesn't usually require a special visit to a urologist. Additionally, measurement of blood levels of testosterone isn't helpful or necessary. Rick and I agree that this last is very important as testosterone levels are of increasing interest lately as the role of the hormone is scrutinized in everything from congestive heart failure to muscle preservation to osteoporosis, as is the potential utility for testosterone replacement therapy. Understanding where testosterone is and isn't a factor must underpin its use.

Other topics in this week's podcast include a new obesity drug reported on in the Lancet, fish oil and an antidepressant in people with both cardiovascular disease and depression in JAMA, and treatment of kids with kidney disease in NEJM. Until next week, y'all live well.

Viral Cause for Chronic Fatigue?

2009-10-19T05:24:00.000-07:00

Chronic Fatigue Patients Vindicated?

Imagine developing fatigue so profound you're almost unable to get out of bed, much less participate in activities requiring any physical effort. Now add to that muscle aches and pains and cognitive difficulties. To complete the picture, let's say these symptoms persist for months and are unrelieved by rest, no matter how much you get. The cause? Chronic fatigue syndrome or CFS, a much maligned syndrome even or especially largely disparaged by the medical establishment.

Now CFS and those afflicted by it may finally get some respect. That's because a potential viral cause for CFS has been identified by an astute researcher and published in this week's Science: Detection of an Infectious Retrovirus, XMRV, in Blood Cells of Patients with Chronic Fatigue Syndrome. XMRV, for xenotrophic murine leukemia virus-related virus, was found in 67% of 101 patients with the syndrome, while only about 4% of people without the syndrome were infected. When the researcher looked for antibodies to the virus, 95% of those with CFS had them, indicating that they had been exposed to the virus at some point.

Does this establish a cause and effect relationship, such as that for HIV and AIDS? No, not yet. Further studies will be needed to nail that down. But what it does do is point researchers in a direction for investigation, and in the short term, may legitimize CFS as a real physical illness and not a case of malingering.

Rick and I are both of the opinion that finding a virus lurking about is no surprise, and again, HIV is a great example. When 'acquired immune deficiency' came on the domestic scene in the 1980s, no one knew what was causing it. Rigorous investigation finally turned up HIV as the culprit, and now we know that a number of its cousins are important pathogens for animals as well. We also know from our experiences with 'bird' and 'swine' flu, that viruses that will ultimately end up as pathogens in people are fermenting in animal populations all the time. This may be one more example.

Other topics in this week's podcast include JAMA's early release articles on H1N1, and comparative effectiveness of methods to remove the prostate gland, and in Archives of Internal Medicine, whether your neighborhood could increase your chances of developing type 2 diabetes. Until next week, y'all live well.

Most Likely Foods to Make You Sick

2009-10-12T04:58:00.000-07:00

Healthy Foods May Make You Sick

A watchdog organization called the Center for Science in the Public Interest has released a list of the top ten foods regulated by the FDA that cause food borne illness. Far and away, the winner is leafy green vegetables, causing more than 13,000 diagnosed cases of what is frequently called 'food poisoning' since 1990. And since most cases of food borne illness aren't ever diagnosed or reported, the actual number is likely much, much higher.

Rounding out the list in descending order of illness causation are eggs, tuna, oysters, potatoes, cheese, ice cream, tomatoes, sprouts, and berries. What's so disconcerting, of course, about this list is that the majority of these foods would be deemed 'healthy' by most people. So why do these foods harbor more pathogens than others?

Rick points out that the very nature of how many of these foods are grown or produced puts them in contact with potential disease causing organisms. As 'natural' foods (other than the ice cream), they are consequently in contact with nature and its host of residents, some friendly to our gastrointestinal tracts and some not. So what's your best defense?

That old standby, soap and water, should be used copiously. Even washing foods you peel, such as avocados or oranges, before removing the peel is prudent. Don't cut raw meats and fruits or vegetables on the same surface using the same utensils. Refrigerate foods that require it promptly. Don't reuse plates or platters that have had raw meats on them after cooking- either wash them or use another platter.

So in spite of these measures, you develop diarrhea or vomiting after eating something you suspect may have been contaminated. Should you seek medical attention? Only if you have bloody or prolonged diarrhea or you have a high fever. Folks who have immune system compromise may need to be a bit more vigilant, but for most of us, several uncomfortable hours will pass and the episode will be over. And increasingly, oversight measures should help prevent many of these outbreaks. Certainly you should keep the majority of these foods on your 'do eat' list.

Other topics on this week included Using Nontraditional Risk Factors in Coronary Heart Disease Risk Assessment and Effectiveness and Cost-Effectiveness of Vaccination Against Pandemic Influenza in Annals of Internal Medicine, and Defibrillator Implantation Early After Myocardial Infarction in NEJM. Until next week, y'all live well.

Weight Loss and Apnea

2009-10-04T05:53:00.000-07:00

More Benefits Seen With Weight Loss

For folks carrying around a few too many extra pounds, the benefits of losing weight can hardly be overestimated from a medical standpoint, even for those who are only modestly overweight. Cardiovascular disease, diabetes and arthritis all improve when extra poundage is shed, and now sleep apnea-that condition where people stop breathing during sleep-has joined the list.

In this issue of Archives of Internal Medicine, A Randomized Study on the Effect of Weight Loss on Obstructive Sleep Apnea Among Obese Patients With Type 2 Diabetes, established that even modest weight loss was associated with significant improvement in sleep apnea. As might be expected, the more weight study participants lost, the greater the benefit.

While physicians who manage patients with sleep apnea have reported for years that weight loss helps, in so-called anecdotal reports, this is the largest, longest prospective study to specifically design an intervention, assess it, and chronicle its impact on episodes of breathing cessation during sleep. Such evidence is important to accumulate in order to convincingly prove the benefits of a specific intervention or therapy.

A previous study Rick and I reported on showed that sleep apnea is associated with an increased risk of death from any cause, not just cardiovascular problems. This effect was most pronounced in men younger than 70. Clearly this is a risk group where weight loss should be encouraged. Rick also points out that lifestyle interventions such as weight loss and increased exercise have no deleterious side effects and allow people to become fully engaged in their own health. In sum, a win-win all around.

Other topics this week included Shared Decision Making for Prostate Cancer Screening, also in Archives, and Cardiac-Resynchronization Therapy for the Prevention of Heart-Failure Events and Variation in Hospital Mortality Associated with Inpatient Surgery in the New England Journal of Medicine. Until next week, y'all live well.

Women and Heart Disease

2009-09-21T06:02:00.000-07:00

No Help for Women with Congestive Heart Failure

Most studies of cardiovascular disease and its manifestations have been done in men. That's an undisputed truth. In view of this fact, much of the clinical management of heart disease in women is extrapolated from data gleaned studying men. Unfortunately, just like calculating medicine dosages for children based on studies in adults, it doesn't work. Children are not little adults, and women are not men with different anatomy.

The latest study to bear this out is Effectiveness of Implantable Cardioverter-Defibrillators for the Primary Prevention of Sudden Cardiac Death in Women With Advanced Heart Failure in the current issue of Archives of Internal Medicine. This meta-analysis, where data from a multitude of studies is pooled and analyzed together, looked at the impact of implanting an automatic defibrillator, a device designed to monitor the heart and shock it back into a normal rhythm when it isn't working right, in women with congestive heart failure.

The study found that not only wasn't the defibrillator helpful in these women, the very act of implanting it was associated with a higher rate of complications. The authors offer a number of speculations on why the device doesn't help women with congestive heart failure since it so demonstrably does help prevent sudden cardiac death in men. Some of the factors they mentioned include more advanced heart failure among women in the study, higher blood pressure and a higher rate of diabetes.

Rick and I agree that the take home message from the study is clear: heart disease and it's complications are very different between men and women. We've seen this in the past with the Framingham Heart Study, where risk factors for heart disease identified in men haven't turned out to compute a complete picture for women. We also know that many women present with different symptoms than men when they are experiencing a heart attack: men may feel classic symptoms like pain radiating down the left arm and neck or a crushing sensation in the chest, but women may only identify a vague feeling of dread or a sensation they think may be indigestion.

What does this mean for women at high risk for cardiovascular disease or those who already have congestive heart failure? It means women and their families must advocate for themselves when it comes to management of their condition and stay abreast of new research related specifically to women. Rick also makes the plea that more women agree to participate in clinical trials, as only 18% of the study subjects in these studies cited in the meta-analysis were women.

Other topics for this week included Small-Intestinal Histopathology and Mortality Risk in Celiac Disease in JAMA, and Dabigatran versus Warfarin in Patients with Atrial Fibrillation and Inhibition of the Hedgehog Pathway in Advanced Basal-Cell Carcinoma and Treatment of Medulloblastoma with Hedgehog Pathway Inhibitor GDC-0449 in NEJM. Until next week, y'all live well.

Docs in a Box

2009-09-14T06:16:00.000-07:00

Retail Medical Clinics

'Doc in a box' is the tongue in cheek, and admittedly somewhat disparaging term many medical insiders call retail medical clinics, such as those found in Target or Wal Mart stores. These clinics purport to offer quick, accessible care for common medical problems, and as Rick points out in this week's podcast, they really should be called 'nurse in a box' since the majority are staffed by nurse practitioners.

The question is, how good is the care provided by these clinics? A study in the latest issue of Annals of Internal Medicine, Comparing Costs and Quality of Care at Retail Clinics With That of Other Medical Settings for 3 Common Illnesses, examined this question. Researchers looked at care received for middle ear infections, sore throats and urinary tract infections in such clinics compared to that in physician offices, urgent care facilities and emergency departments. Measures of quality included cost of the visit, cost of prescriptions related to the visit, and whether patients received preventive care as well as an aggregate quality score.

Turns out that retail clinics fared very well indeed, costing substantially less than other medical providers for the care itself, with prescription costs and provision of preventive services about equal. Metrics I would have liked to see include how long it took to be seen and whether patients themselves were satisfied with their care. In any case, diagnoses were overwhelmingly correct as those seen in the clinics weren't subsequently seeking care for the same condition elsewhere.

Seems like people can feel confident that if they're seeking treatment for garden variety ailments such as a sore throat, a retail clinic will serve the purpose. Perhaps those of us in the medical establishment should embrace these clinics, since as Rick says, they remove some of the burden of care from emergency departments. One caveat: for continuing care, or continuity of care, it's still best to have a primary care provider in your corner.

Other topics in this week's podcast included two more from Annals: Effects of a Mediterranean-Style Diet on the Need for Antihyperglycemic Drug Therapy in Patients With Newly Diagnosed Type 2 Diabetes and Systematic Review: Comparative Effectiveness and Harms of Combinations of Lipid-Modifying Agents and High-Dose Statin Monotherapy , and in JAMA, Typhoid Fever in the United States, 1999-2006. Until next week, y'all live well.

Statins Before Surgery

2009-09-07T12:59:00.000-07:00

Benefits of Statins Before Vascular Surgery

Rick and I have quipped frequently in the four years we've been doing PodMed that soon statins, that class of drugs used to lower cholesterol, will be added to drinking water, a lot like fluoride. That's because in many reports and studies, the benefits of statins seem legion. Now comes a study in NEJM showing another benefit. When people have vascular surgery, or surgery on their blood vessels, those who receive statins experience fewer cardiovascular events than those who don't: Fluvastatin and Perioperative Events in Patients Undergoing Vascular Surgery.

People who need vascular surgery are at high risk for subsequent heart attacks and other cardiac events, some of them resulting in death. This study took 499 patients and started about half of them on a statin almost 40 days prior to surgery, with the other half not receiving the drug. Patients were followed for 30 days following surgery.

Those who took the statin experienced about half the rate of heart attack or death from a cardiac event than those who did not take the statin. As might be expected, statin takers had reduced cholesterol and blood markers of inflammation than those who did not. While no one knows exactly why statins have this beneficial effect, this last is a common hypothesis: they reduce inflammation and its consequences.

What does this mean for statin use prior to surgery? Clearly, surgery on this group of people was planned and allowed for initiation of statin therapy well before surgery took place. That's not a luxury everyone who will undergo surgery has, and no one knows how helpful the drugs might be in an acute setting. Also, this benefit is only seen in folks who are not taking statins already, as so many people are. Yet the fact remains that statins once again seem to offer additional benefits besides lowering cholesterol, and no doubt more will emerge as studies are reported.

Other studies we discuss in this week's podcast include Injectable Collagenase Clostridium Histolyticum for Dupuytren's Contracture, also in NEJM, and two studies in this week's JAMA: Treatment of Bell Palsy and Chronic Pelvic Pain and Nerve Ablation (hyperlinks not available at time of blog posting). Until next week, y'all live well.

Dangers of Radiation Exposure

2009-08-31T04:35:00.000-07:00

There's a long term health consequence from exposure to the type of radiation used for many medical imaging studies. That fact emerges clearly from the burgeoning literature on the subject. Questions that remain unanswered are just how significant is the risk? Are certain types of studies most problematic? And how big is the problem anyway? This week's NEJM attempts to get a handle on this last, with some rather astonishing results.

Exposure to Low-Dose Ionizing Radiation from Medical Imaging Procedures reveals that after surveying almost a million people aged 18 to 64 (!) just about 70% of them had some sort of medical imaging study in the previous two years. Yikes. Talk about a number that's simply huge. For most of these folks CT and nuclear imaging studies were the radiation source, and as might be predicted, exposure increased with increasing age. Yet the point to be made is these were relatively young, healthy people, so exposure is taking place earlier in life than we'd probably like.

That is the issue, of course. The dangers of radiation exposure are cumulative, and the younger someone is when exposure begins the more potentially hazardous this may be down the road.

Medical imaging equipment manufacturers are acutely aware of this and to their credit, are constantly improving capabilities to minimize exposure as much as possible. There's no doubt that physicians are also becoming much more tuned in to the issue and are questioning the need for such studies as well, although as our colleague Elliot Fishman, professor of radiology points out, if it's exploratory surgery to assess an inflamed appendix or abdominal CT, the risk benefit analysis is quite clear.

For now, a couple of things to keep in mind when your physician orders a study: ask about the need for the study, choose a center with the latest equipment, and inform your physician about your history of such imaging studies. Yet one more place where your best health advocate is yourself, and one more reason to keep your own complete health record.

Early Diagnosis of Myocardial Infarction with Sensitive Cardiac Troponin Assays and Sensitive Troponin I Assay in Early Diagnosis of Acute Myocardial Infarction, also in NEJM, and Association of Cytochrome P450 2C19 Genotype With the Antiplatelet Effect and Clinical Efficacy of Clopidogrel Therapy and Hormonal Therapy Use for Prostate Cancer and Mortality in Men With Coronary Artery Disease–Induced Congestive Heart Failure or Myocardial Infarction in JAMA rounded out the podcast for this week. Until next week, y'all live well.

Who Spots Melanoma?

2009-08-22T02:43:00.000-07:00

How is Melanoma Most Often Detected?

Statistics surrounding melanoma, the most lethal form of skin cancer, are grim. The World Health Organization reports about 48,000 deaths due to melanoma each year, with approximately 160,000 new cases diagnosed yearly. A study in this week's Archives of Dermatology: Routine Dermatologist-Performed Full-Body Skin Examination and Early Melanoma Detection sheds new light on diagnosis.

First of all, Rick and I would like to offer kudos to the author, who simply took it upon himself to assess whether melanomas were detected more often when a patient asked him to look at a skin lesion or if he did a full body skin examination. Surprise! About 60% of these skin cancers were detected by the physician, not because the patient came in and said, hey doc, look at this. And when the lesions were detected by the physician they were smaller and thinner, and therefore less likely to have spread and certainly easier to remove.

Full body skin examinations have been discussed for years among medical professionals, with some saying they should be done annually. This study would suggest that people should ask their dermatologist to conduct such an exam if one isn't suggested to them. Melanomas are notorious for popping up in all sorts of unlikely places: between the toes, on the scalp beneath a full head of hair, inside the ear. Certainly places it would be difficult or impossible to examine on your own.

If you or a partner or friend do see something suspicious, the ABCDE method of assessing potential melanomas may be applied: A for asymmetrical, B for irregular border, C for color, with most lesions having more than one color, D for diameter, often greater than 5 mm, and E for elevation, since raised lesions may be more troublesome, or evolution, with the lesion changing over time to get bigger.

Prevention, as always, is preferable: avoiding the sun from 10am to 2pm, wearing protective clothing and a hat, and perhaps sunscreen, although that's controversial. Other topics in the podcast this week include Effects of a Palliative Care Intervention on Clinical Outcomes in Patients With Advanced Cancer and Postlicensure Safety Surveillance for Quadrivalent Human Papillomavirus Recombinant Vaccine in JAMA, and Systematic Review: Elective Induction of Labor Versus Expectant Management of Pregnancy in Annals of Internal Medicine. Until next week, y'all live well.

The Many Benefits of Aspirin

2009-08-18T05:21:00.000-07:00

Anyone who's watched the excruciating process by which a new drug gains FDA approval knows that if garden variety aspirin, that mainstay of medicine cabinets everywhere, was up for review today, it would never make the cut. That's because aspirin is known to have a number of negative side effects, especially gastrointestinal bleeding. But now another study in JAMA is extolling the benefits of aspirin: Aspirin Use and Survival After Diagnosis of Colorectal Cancer.

The study followed over 1200 men and women with various stages of colorectal cancer and examined deaths and aspirin use. Those who used aspirin, also at varying dosages, experienced fewer recurrences and deaths related to colon cancer than those who did not. Tumor analysis revealed that aspirin responders had more of an enzyme in their tumors called cyclooxyenase 2, abbreviated COX-2. This is the same enzyme (which can be thought of as a helper to chemical reactions) that is the target of prescription drugs like Celebrex.

Once again we're hearing about how interfering with COX-2 can be beneficial, and aspirin is a cheap, effective way to do so. We already know that aspirin is recommended for many at risk of heart attacks, and it may have utility in other preventive settings as well. But the bottom line, as Rick points out, is that before embarking on regular aspirin use, you should consult your primary care physician. That's because aspirin in conjunction with other medications may be harmful, and you may have other medical conditions that preclude its use.

Another aspect to this study we've been hearing so much about is tumor analysis and personalized medicine. Checking to see whether colon tumors express COX-2 would predict who is likely to benefit and who is not.

Other topics on our podcast this week include Physical Activity, Diet, and Risk of Alzheimer Disease and Adherence to a Mediterranean Diet, Cognitive Decline, and Risk of Dementia, also in JAMA, and Weight Lifting in Women with Breast-Cancer–Related Lymphedema from NEJM. Finally, there's Carriage of Methicillin-Resistant Staphylococcus aureus in Home Care Settings. Until next week, y'all live well.

Flu Deadly During Pregnancy

2009-08-10T05:56:00.000-07:00

H1N1 Infection in Pregnancy

H1N1 infection in pregnant women seems to be associated with a much higher rate of mortality than any other group reported so far. That's according to a Lancet Infectious Disease study: H1N1 2009 influenza virus infection during pregnancy in the USA. In this relatively small number of women (34), 11 were admitted to the hospital and 6 of them died. So mortality was approximately 50% among those hospitalized with the flu.

That is, of course, a very high rate of mortality. These women died of primary pneumonia related to the influenza infection. They developed pneumonia and its consequent breathing problems several days after being infected with H1N1. In contrast, many people who have had the flu may develop secondary pneumonia, often with a bacterium such as Streptococcus pneumoniae. This happens because their immune systems are weakened from the flu and the bacterium gains the upper hand, causing pneumonia. One public health message from this more typical scenario is if you have had the flu, seem to be getting better and then suddenly develop a fever and perhaps breathing problems, seek immediate medical attention.

The advice for pregnant women is even more urgent: if you have what appears to be the flu, with fever, muscle aches and pains, perhaps respiratory symptoms, go to an emergency department. H1N1 remains sensitive to oseltamivir and zanamivir, two antiviral drugs, but drug therapy must be initiated early in the course of infection to be effective. Women who died in this study did not receive the medications in a timely fashion, most likely because of health care providers' reluctance to use any medications during pregnancy. Indeed, no one knows the effect of antiviral drugs on the developing fetus, but we do know that untreated women will die at a high rate. Keeping mom alive, therefore, seems to win out in the risk/benefit analysis.

Another public health message is if you're pregnant or contemplating pregnancy, get a flu shot. Other topics in our podcast this week include: Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): a multicentre, open-label randomised controlled trial, Addition of infliximab compared with addition of sulfasalazine and hydroxychloroquine to methotrexate in patients with early rheumatoid arthritis (Swefot trial): 1-year results of a randomised trial, both from the Lancet, and Screening for Intimate Partner Violence in Health Care Settings from JAMA. Until next week, y'all live well.

Osteoporosis Impact

2009-08-03T06:04:00.000-07:00

Osteoporosis is an increasing problem worldwide, largely as a consequence of many more people living long enough to develop the bone-thinning condition. Most concerning is the trajectory from the development of osteoporosis to bone fractures to nursing home care to death, delineated in many studies.

Now the federal Agency for Healthcare Research and Quality has sounded an alarm with release of statistics on the treatment of osteoporosis-related hip, pelvis and other fractures between 1995 and 2006, showing an increase in related hospitalizations of 55% during that period. http://www.ahrq.gov/news/nn/nn071709.htm Yikes! It's sure looking like public education efforts notwithstanding, many more people are experiencing the serious manifestations of osteoporosis.

We have very effective, painless screening methods to detect the condition, especially dexa scanning, a type of X-ray. We also have medications, particularly a class of drugs called bisphosphonates, to treat osteoporosis. Best of all, of course, is prevention. That most likely entails weight-bearing exercise such as walking and taking a calcium supplement. These are especially helpful in combination because bones respond to stress by laying down more bone and depositing minerals such as calcium within them.

It's worth mentioning that while the majority of people affected in this study were women, men are increasingly represented in the ranks of those with osteoporosis, especially men aged 80 and beyond. Once again, prevention, screening and treatment are the best options. Other topics this week include another release from the AHRQ: New AHRQ Study Finds Mixed Evidence on Use of Radiofrequency Catheter Ablation for Treating Atrial Fibrillation, one from NEJM: Effects of Pay for Performance on the Quality of Primary Care in England and two from the Lancet Closure of schools during an influenza pandemic and Influenza in immunosuppressed populations: a review of infection frequency, morbidity, mortality, and vaccine responses.

Lifestyle Again!

2009-07-26T05:31:00.000-07:00

Once again, two studies published in this week's Journal of the American Medical Association,
Relation Between Modifiable Lifestyle Factors and Lifetime Risk of Heart Failure and Diet and Lifestyle Risk Factors Associated With Incident Hypertension in Women establish that staying physically active, not smoking, choosing your food carefully, and avoiding weight gain are keys to a longer, healthier life. And then there's my personal favorite, judicious consumption of alcohol. Duh.

In women, these actions or inactions lessened the chance for developing high blood pressure, with its consequent risk of stroke and other cardiovascular problems. The data came from a huge, long term study called the Nurses Health Study. And in data gathered from the Physicians Health Study, a huge study of male doctors, reduced the risk for heart failure, a major killer of older folks.

Yawn. Unless you've been living under a slimy rock, you know all this. But there were a couple of newer observations from each study: in the nurses, frequent use of non-steroidal antiinflammatory medications, including ibuprofen and acetaminophen, increased the risk of developing high blood pressure. And folic acid, a B vitamin, reduced the risk.

In the heart failure study, consumption of breakfast cereal emerged as a protective factor. I would love to see this broken down further, since I question whether Cap'n Crunch confers the same benefit as Cheerios. In any case, the take home messages are clear:

Exercise, don't gain weight, don't smoke, eat a healthy diet high in fruits and vegetables and low in salt, consume alcohol moderately, use over the counter pain relievers as infrequently as possible, and eat breakfast cereals. Since many of these are fortified with folic acid already, that may help satisfy that condition as well.

What's abundantly clear from all of this is the final message: You can take charge of your own health. Both titles include the word 'lifestyle.' Clearly, your lifestyle choices are your own. And as Rick always signs out, "Y'all live well."

Other topics this week include CSF Biomarkers and Incipient Alzheimer Disease in Patients With Mild Cognitive Impairment, also from JAMA, and from NEJM Peginterferon Alfa-2b or Alfa-2a with Ribavirin for Treatment of Hepatitis C .

High Tech Colon Assessment

2009-07-19T05:00:00.000-07:00

Can Your Colon be Examined with a Pill?

Most of us know the recommendation by now: If you're at average risk for colon cancer, once you reach the age of fifty you should have a colonoscopy to screen for the disease, as well as precancerous lesions called polyps. But who wants to undergo this test? It's even less fun than mammography (an issue I can speak to), requires a day of preparation where it's almost impossible to leave the house, sedation and the need for a driver to provide transport home. Jokes abound about screening colonoscopy, and Katie Couric's courage notwithstanding, the majority of those eligible for screening choose not to have it.

So would the test be more acceptable if it just involved swallowing a pill, albeit a pretty big one? The PillCam measures 31 by 11 millimeters. (Read the fine print: bowel preparation still required.) This test merely requires swallowing the device, pictured above, and continuing to drink the same solution used to cleanse the bowel in traditional screening colonoscopy. As the "PillCam COLON capsule" makes its way through the GI tract it snaps pictures. The device is recovered by the patient and the images uploaded for analysis by the healthcare provider.

Capsule Endoscopy versus Colonoscopy for the Detection of Polyps and Cancer is published in this week's NEJM. Results were disappointing, with only about three-quarters of the lesions found at colonoscopy also identified with the device.

So it's looking like traditional colonoscopy is still the way to go, at least for now. Other topics we talked about this week include Disclosure of APOE Genotype for Risk of Alzheimer's Disease and Longitudinal Modeling of Age-Related Memory Decline and the APOE 4 Effect, also in NEJM, and Coronary Artery Calcification Screening and Active Commuting and Cardiovascular Disease Risk in this week's Archives of Internal Medicine. Until next week, y'all live well.

Trichotillomania Treatment (!)

2009-07-12T06:03:00.000-07:00

An Effective Treatment for Chronic Hair Pulling

Lots of people engage in repetitive behaviors; most of us eat on a regular basis for example. But some people engage in behaviors they repeat over and over again, sometimes resulting in personal harm, and over which they cannot seem to exert control. Such behaviors are then termed 'compulsive.' One such is trichotillomania, or chronic hair pulling. (The word itself isn't as bizarre as it sounds. Tricho always refers to hair, tillo to pull out, and mania, insanity.) Those who manifest trichotillomania will pull out their own hair, creating bald patches. But now a good news study in this week's Archives of General Psychiatry suggests an effective treatment.

Even better, the treatment used in this study is available over the counter in many health food stores, doesn't seem to have any deleterious side effects and points the way toward an understanding of why people pull their hair out to begin with.

N-acetylcysteine, 1200-2400 milligrams per day, was used by study participants for 12 weeks. 56% of those taking the supplements reported themselves "much or very much improved" compared to 16% of the folks who weren't taking N-acetylcysteine (the control group). The effectiveness of this treatment seems to indicate that glutamate, a chemical used by cells in the brain and elsewhere to communicate, may be too low, and giving this supplement helps.

Previous studies on this condition had focused on serotonin, the darling of the depression world, with conflicting study results. Shifting the focus to glutamate may also help in the management of other compulsive behaviors.

Other topics this week included Adiponectin Levels and Risk of Type 2 Diabetes in JAMA, Travel and Risk for Venous Thromboembolism and Working Conditions in Primary Care: Physician Reactions and Care Quality in Annals of Internal Medicine. Until next week, y'all live well.

Heart Disease Bystander?

2009-07-05T04:50:00.000-07:00

Is C-reactive Protein a Villain or an Innocent Bystander?

C-reactive protein or CRP is a blood marker of inflammation. First identified in the 1930s, CRP has been intensively studied in the hopes of imbuing it with some predictive power: the higher the CRP level, the higher the risk of cardiovascular disease would be one way of crystalizing a looked for relationship, with clear cause and effect the ideal. Sadly, such a relationship has had a bit of an on-again, off-again character, and in this week's JAMA, two studies further erode CRP's clinical utility.

'Novel and Conventional Biomarkers for Prediction of Incident Cardiovascular Events in the Community' is one of the studies. It assessed CRP levels and other so-called 'novel' blood markers as well as conventional measurements in thousands of people, then asked the question: does the addition of CRP and other biomarkers markedly improve our ability to predict who will develop cardiovascular disease? The answer was largely no.

A second study ('Genetic Loci Associated With C-Reactive Protein Levels and Risk of Coronary Heart Disease') looked at genetic variations associated with CRP levels and found that no cause and effect relationship exists. In other words, CRP is not the smoking gun when it comes to cardiovascular disease. It may be lurking about in the shadows, but it isn't the trigger man.

As Rick says, we are really quite good at using conventional risk factors for predicting who will develop cardiovascular disease for the vast majority of people. Overweight and obesity, diabetes, high blood pressure, sedentary lifestyle, smoking, high cholesterol, and a family history of heart disease are all pieces of the puzzle. The addition of CRP measurement to this doesn't help in the majority of people, although it may help a little bit in those at intermediate risk.

Other topics this week include the risks of walking aids for the elderly to be published in the Journal of the American Geriatrics Society, but here's a news story:http://health.yahoo.com/news/ap/us_med_elderly_falls.html , another swine flu update from NEJM , and failure to prevent kidney complications of diabetes using medications to treat the condition: Renal and Retinal Effects of Enalapril and Losartan in Type 1 Diabetes. Until next week, y'all live well.

Why the Mediterranean Diet Helps

2009-06-28T04:43:00.000-07:00

Why Does the Mediterranean Diet Result in Longer Life?

We've all been hearing it for years: eat more like our Mediterranean cousins do (read that Greeks) and you'll live longer. Such a diet, dubbed the 'Mediterranean diet,' should include olive oil as the main oil consumed, lots of fruits and veggies, and wine, judiciously quaffed. But what exactly about this diet is most important in prolonging life? Investigators at Harvard took a stab at it and published their results this week.

Hands down, the biggest factor in prolonging overall survival was alcohol consumption. Moderate consumption, that is, not low or high, and almost always with meals. And of course we're already aware that the vehicle for this alcohol is almost always wine. In fact, just about a quarter of the survival benefit (23.5%) of the Mediterranean diet is accounted for by the wine.

Other factors in order of importance were low consumption of meat and meat products (16.6%), high vegetable consumption (16.2%) and high fruit and nut consumption (11.2%). The big surprise though, was the relative lack of benefit of eating fish, which the authors account for by revealing that this population just doesn't eat that much seafood, and a lack of benefit of cereals. Here they speculate that the category includes too many diverse products for analysis.

So what's the take home message? Even though it's tempting for us to dissect out the factors that seem to be most important (resveratrol in wine, for example), it's likely the combination that's most helpful. And Rick and I both agree that an extended Greek vacation (Paros, anyone?) would be welcome.

Other topics this week include Migraine Headache in Middle Age and Late-Life Brain Infarcts from JAMA, Frequency of Failure to Inform Patients of Clinically Significant Outpatient Test Results from Archives of Internal Medicine, and the best way to treat heart attacks involving total blockage of the blood vessels in this week's NEJM: Routine Early Angioplasty after Fibrinolysis for Acute Myocardial Infarction. Until next week, y'all live well.

Home Test for Dementia

2009-06-20T17:05:00.000-07:00

A New Do It Yourself Screening Test for Dementia

The British Medical Journal has reported a new self-administered screening test for Alzheimer's dementia: Self administered cognitive screening test (TYM) for detection of Alzheimer’s disease: cross sectional study. Just like so many other tests like HIV status, pregnancy, and blood sugar measurements, now people can take 15 or so minutes and in the privacy of their own home, determine if there's sufficient evidence of a problem to seek further evaluation.

Numbers on the test are interesting: in the subjects who were tested in the study, those who scored better than 42 out of 50 could be 99% sure they didn't have Alzheimer's disease. In the group who already knew they did, based on other tests, the TYM, for 'test your memory.' was also fairly good at making the diagnosis. But in another group in whom 10% would be expected to have Alzheimer's disease, it only picked up just over 40%.

Why would you want to find out you may have Alzheimer's disease while at home, perhaps alone? When home HIV tests became available there was lots of discussion of the risks involved in getting a positive result: would people get so depressed they'd commit suicide? Another argument about screening surrounds treatment: in the absence of an effective treatment for the condition, why screen?

Rick makes the point that there are strategies and even medicines that have been shown to slow the progression of Alzheimer's disease. Brain training, physical exercise, a small group of medicines are a few examples. And advance planning is possible as well. So perhaps the TYM will be useful as more and more people develop Alzheimer's dementia, a number that is expected to double every 20 years.

Other topics this week included HPV testing in combination with liquid-based cytology in primary cervical screening (ARTISTIC): a randomised controlled trial from the Lancet, a number of articles from this week's New England Journal of Medicine on swine flu, and Corticosteroids vs Corticosteroids Plus Antiviral Agents in the Treatment of Bell Palsy from Archives of Otolaryngology. Until next week, y'all live well.

June 14, 2009

2009-06-14T16:41:00.000-07:00

The big story this week was a recommendation by an international body of experts, including the American Diabetes Association, to use a test called hemoglobin A1C, often abbreviated HbA1C, or even simply A1C, to diagnose diabetes.

A1C is based on the fact that sugar molecules lurking about in the blood will attach to hemoglobin, the oxygen carrying molecule found in red blood cells. Red blood cells survive for a couple of months, so testing how much sugar is attached to them provides an average of blood sugar over that time period. The average is very important as all of us have spikes and valleys in our blood sugar daily.

This test will now replace two older tests: fasting plasma glucose, where people needed to have their blood drawn before eating anything that day (hopefully first thing in the morning!) or the oral glucose tolerance test, where they drank several ounces of a very sugary liquid and then had blood drawn periodically afterward to see how high the blood glucose went and how quickly it came back down afterward. Both tests had their down sides.

A1C can be drawn at any time of the day and whether or not someone has eaten. The level considered to indicate diabetes is given as a percent, and the number is 6.5. So if your A1C is 6.5% or higher that means you very likely have diabetes. As Rick says, it may take some time before everyone is using A1C and the other tests are abandoned, but you can certainly ask for this test rather than the other ones if you're being evaluated for diabetes.

Other stories this week included A Randomized Trial of Therapies for Type 2 Diabetes and Coronary Artery Disease, The Safety of Metoclopramide Use in the First Trimester of Pregnancy, and Genetically Elevated Lipoprotein(a) and Increased Risk of Myocardial Infarction. Until next week, follow us on Twitter! And to quote Rick, Y'all live well.

June 7, 2009

2009-06-07T05:03:00.000-07:00

Computers Can Help People Quit Smoking

It's no surprise to anyone that smoking is the number one cause of preventable death worldwide. I've said a number of times in our podcast that if some universal authority empowered me to make just one decision to benefit everyone's health I would immediately abolish cigarettes. That said, and in an attempt to avoid a rant, this week Rick and I talked about the use of computer-based programs to assist people in their efforts to quit smoking: Effects of Web- and Computer-Based Smoking Cessation Programs in this issue of Archives of Internal Medicine.

While this is a meta-analysis, a type of study we normally disparage because it throws a bunch of studies together and then draws conclusions that may or may not be valid, this study does show that computer-based programs do help. And anything that helps, especially when it comes to smoking cessation, is great.

Web based programs have so many advantages: they're convenient, they create communities of like-minded folks, and they can be personalized. One really interesting aspect to the study was these programs don't seem to work for that group of people who are the most computer-savvy: teenagers. Rick and I both found that really fascinating as we are regularly outclassed by our kids when it comes to technology use.

So for now, if you're trying to quit smoking, congratulations! By all means use a web based program to help, and keep in mind that previous research shows that the more modalities you use the better your chances of success. That might mean nicotine replacement, support groups, perhaps hypnosis or cognitive behavioral therapy. And remember, no matter when you quit there are always immediate health benefits.

Other topics this week included a risk score for type 2 diabetes, swine flu update, and the lack of benefit in stopping hormone replacement before mammography, all in the latest issue of Annals of Internal Medicine. Until next week, y'all live well.

May 29, 2009

2009-05-31T04:55:00.000-07:00

Guys who play football professionally are probably in great shape, right? They work out all the time, pay close attention to what they eat and get regular physical exams. Turns out though, that the majority of professional football players have either high blood pressure or the condition that precedes it known as prehypertension. That's in this week's JAMA, Prevalence of Cardiovascular Disease Risk Factors Among National Football League Players

We've known about an association between a lot of weight lifting and high blood pressure for a while, and that's what I suspect is the driver here. Rick points out that other factors may also be involved: use of that class of pain relievers known as nonsteroidal antiinflammatory medications (NSAIDs) such as ibuprofen, or perhaps use of supplemental salt, ostensibly to replace that lost via sweat. Probably not necessary, Rick opines. In any case, the NFL is planning to start screening players for high blood pressure, and for those of you weight lifting fans out there, having your blood pressure measured is a good idea. As is adding a significant cardiovascular component to your workout.

Speaking of good ideas, turns out that what everyone thought was a good idea isn't. That's the use of compression stockings, which almost everyone complains about, in people who've had a stroke. The study is in this week's Lancet, Thigh-length compression stockings and DVT after strokeThe Lancet, In Press, Corrected Proof, Available online 26 May 2009. Not only didn't these stockings prevent blood clots, but people who used them had skin problems. So here's something to safely give a miss.

Not to miss, however, is balance assessment. A Johns Hopkins study published in Archives of Internal Medicine, http://archinte.ama-assn.org/cgi/content/short/169/10/938, shows that about 30% of US adults over the age of 40 have a balance problem. This is especially bad because it can lead to falls, broken bones, nursing home stays, and death, a trajectory that is well established in older folks. Lloyd Minor, one of the study's authors, points out that while most of us can identify problems with hearing or sight, balance issues are much sneakier in their onset and may worsen so slowly over time that people may not come to their doctor with a specific complaint. Screening is easy, and there are specific things people can do to reduce their risk of falls, like removing throw rugs, using a cane or other aid for walking, and 'vestibular retraining,' which sounds kind of scary but isn't. So it may be worthwhile to talk with your primary care doc about balance screening.

Our final study this week is from the New England Journal of Medicine. http://content.nejm.org/cgi/content/abstract/360/22/2277. This study describes a technique called radiofrequency ablation for a precancerous condition in the esophagus called Barrett's. This is important because here's the relationship: chronic heartburn ( in medicalese, gastroesophageal reflux disease or GERD) goes to changes in the esophagus called Barrett's esophagitis, goes to esophageal cancer, with a dismal prognosis and often death. Previous to the development of this technique, surgery to remove part of the esophagus was attempted, with a host of problems and mortality. This technique is much less problematic and seems to help a lot at one year of follow up.

Rick and I both agree, however, that the best medicine for GERD is prevention. That means weight loss (!), not eating within several hours of sleeping, reducing consumption of red wine and foods known to cause heartburn, and perhaps use of antacid medications, starting with the lowest tech ones. Wonder if Rick will follow his own advice this week as he is in France on vacation, where the great food and red wine flow?

Until next week, then, Y'all live well.

May 22, 2009

2009-05-24T04:33:00.000-07:00

Good news came this week from Annals of Internal Medicine, http://content.nejm.org/cgi/content/short/360/21/2165, to those of us who have arthritis in our hands, specifically in the thumb joint. Not rheumatoid arthritis, the one that often causes deformed joints and is the result of the immune system gone awry, but osteoarthritis, that very common condition usually affecting knees and hips. Turns out that the very simple intervention of using a splint to immobilize the thumb, worn only at night, resulted in significant pain reduction and increased ability to use the thumb joint over time.
The splint itself, pictured here, was custom made, and is designed to keep the thumb immobilized but allow use of the fingers and hand. Participants liked it, and kept using it. Rick and I think we'll get one, too, since we both have this condition and there are no downsides to using it. A win-win all around!

Speaking of win-wins, looks like hospitals that do lots of bypass procedures (high volume) may not always win out over low volume hospitals in terms of how well patients do over time. The missing factor here is quality- do patients get proper medications following the procedure? How good is nursing care? Also in this issue of Annals of Internal Medicine, http://www.annals.org/cgi/content/abstract/150/10/696, this study looked at CABG- coronary artery bypass grafting, and found that if quality measures were in place, patients in low volume hospitals did just as well as those in high volume locations. So perhaps not to worry if you need heart bypass surgery and you don't live near a major heart center. But pay attention to those other factors.
Since we're on hearts, this week's New England Journal of Medicine, http://content.nejm.org/cgi/content/short/360/21/2165, took at look at the treatment of acute coronary syndromes. That's when someone comes in to the emergency department with chest pain or other symptoms of a possible heart attack. Do these folks need an immediate trip to the cardiac catheterization lab for a stent or balloon procedure? Not most of the time, and they also don't need to get powerful anti-clotting drugs while they're in the ED but can safely wait until they're needed. This is good because if someone does need to go to the cath lab it can be done at a time when all the appropriate personnel are there (not the middle of the night or on weekends, as often happens) or even at another hospital. Rick is an editorialist on this one and says that these studies will help define who needs urgent attention.
Our last study this week focused on the use of a commonly prescribed medication for older men called Flomax, designed to manage benign prostatic hypertrophy, or BPH, and its negative effects on cataract surgery. That's in the Journal of the American Medical Association. http://jama.ama-assn.org/cgi/content/full/301/19/1991 Turns out men who were taking Flomax had a higher rate of complications when they had cataract surgery, and since millions of men are taking this drug as well as having such surgery, this is potentially a big problem. For now, we know that Flomax helps men initiate urination more easily because it relaxes the muscle called the sphincter. But is also relaxes tiny muscles in the eye, and this gives rise to more problems after cataract surgery. What can be done? That's not known, but possibly stopping the medication a few weeks prior to cataract surgery may help. Men taking Flomax now should advise their ophthalmologist prior to having the procedure- yet one more example of how very important it is for your physician to know ALL of the medications you are taking.
More details on all of these studies in our podcast. As Rick says, until next week, Y'all live well.