Sunday, July 31, 2011
Saturday, July 30, 2011
Friday, July 29, 2011
IGF-1: When More is Less
On the other hand, some of my former colleagues believe in the more is more strategy, especially when it comes to treating growth hormone deficiency. When treating their patients, they believe that everyone should have and be treated to an IGF-1 of 300ng/mL or even higher, based upon reference ranges from older equipment that is not currently being used. This is despite current use of equipment that has a significantly lower upper limit of normal.
Well, in a study released early just 2 days ago (to be published in September), the authors noted a U-shaped curve when comparing all-cause, cancer & cardiovascular mortality to IGF-1 levels. In other words, those participants who had IGF-1 outside the mid-centile reference range, whether high or low, had a greater risk of death, even though their IGF-1 was still within the normal reference range. Of course, this begs the question, what is considered normal?
Well, the normal reference range is that range which includes approximately 95-96% of the "normal" population. Of course, one could always argue whether having two-thirds of our population overweight or obese is really & truly "normal". Nevertheless, we take a bunch of "normal" participants and throw out the lowest 2-2.5% and the highest 2-2.5%, even though they must be "normal" by definition in order to included.
But that still doesn't make us feel any more comfortable about aiming for high (or low) IGF-1 levels. The authors analyzed data from 12 population-based cohort & (nested) case-control studies including 14,906 participants who were deemed normal. For instance, studies of patients w/acromegaly, acute renal failure or liver cirrhosis where excluded. Children & patients in intensive care units were also excluded.
Granted, this is observational data. So one shouldn't necessarily jump to the conclusion that treating to lower (which begs the question, why treat at all) and higher levels is worse or more dangerous/deadly than treating to the mid-range of your lab's reference range. But until proven otherwise, I think the Goldilocks theory of medicine applies here. To wit, give the right amount, not too little, and not too much.
Thursday, July 28, 2011
Cell Phone Use vs Brain Function Part 3
Following medical literature reminds me of watching a (table) tennis game, turning our heads back & forth as we watch the competitors fight it out. Initially, cell phones got a free past with regards to a possible link to cancer. Just over a month ago, a very weak link emerged.
In a study published yesterday in the Journal of the National Cancer Institute, authors analyzed data from close to 1,000 Western European children and found no link between cell phone use and (brain) cancer risk. The good news is that we can now take a deep collective breath and sigh with relief over our children. The bad news is that this study analyzed data only from students who'd used cell phones for 5 years and hadn't really allowed enough time for slower growing cancers to manifest themselves.
So what are we to do? As I mentioned in Part 2, keep the phone away from (your) their faces. This is easier if they text more than they talk. But consider making your children use an earpiece or headset when calling from the phone in order to increase distance and minimize any conceivable damage from radiation. While this is definitely not the definitive and final answer regarding cell phone use, we can certainly feel more comfortable about allowing our children to use this ubiquitous technology. Reporting live from Atlanta, this is Alvin B. Lin.
Wednesday, July 27, 2011
HgbA1c: Readily Available Test Improves Heart Risk Calculation
I started the morning doing an OJ imitation - running thru McCarran, what were you thinking? And now I'm in Atlanta for a meeting. But on the fly, I stumbled upon a study just published today in the Archives of Internal Medicine that demonstrated an improvement in our ability to calculate heart risk with a simple & readily available blood test: Hemoglobin A1c. The authors analyzed data from the Nurses Health Study and the Physicians Health Study over several years. The idea is that HgbA1c is able to assess how poorly one's diabetes is controlled rather than just a blanket statement, as we currently do, to equate any diagnosis of diabetes with heart disease. After all, if you've made the effort to achieve an exceptionally well-controlled HgbA1c, your risk should be lower than the diabetic who doesn't pay attention to his/her nutrition & exercise. So the next time you need blood drawn, see if you can add HgbA1c to your orders.
Tuesday, July 26, 2011
Health Literacy: Does It Matter? Part 3
Two months ago, really close to three months now, I commented on two studies looking at health literacy. The first study linked low health literacy to greater all-cause mortality in patients w/heart failure. The second study linked longer pediatric hospitalization length of stay to parents' lower health literacy. And as I mentioned obliquely last week, low education attainment is considered one of the biggest risk factors for Alzheimer's disease.
Therefore, it's no surprise that I found a systematic review published last week in Annals of Internal Medicine looking at how health literacy affects us. After poring over 96 good or fair quality studies, the authors concluded that low health literacy is associated with more hospitalizations and greater use of emergency care, both of which drive up health care costs.
True, it might not be easy to teach our parents to read, much less understand health-related material. But before this situation explodes in our collective faces, we need to improve upon the education of our children in order to prevent a mushroom of Alzheimer's disease and depletion of our ability to (pay for) care in the very near future.
Monday, July 25, 2011
Don't Just Sit There, Do Something! Part 4
At the same time, two studies were released early online in Archives of Internal Medicine documenting similar conclusions. In the first analysis, 2,809 participants average 72yo with known heart disease in the Women's Antioxidant Cardiovascular Study (WACS) were questioned regarding physical activity every two years while cognitive function was assessed 4 times over 9+years. Those who engaged in the highest quintile of physical activity, equivalent to daily brisk walking for 30 minutes, had slower loss of cognitive decline, comparable to being 5-7 years younger.
In the second study, 197 participants average 75yo in the Health, Aging & Body Composition (Health ABC) study had their total body energy expenditure (TBEE) and resting metabolic rate (RMR) measured along with cognitive function. Consistent with the more typical self-reported physical activity, the higher one's objectively measured active energy expenditure (AEE=TBEE-RMR), the the lower one's risk for cognitive impairment.
Sunday, July 24, 2011
Saturday, July 23, 2011
Friday, July 22, 2011
A Better Way to Assess Heart Disease Risk
Does this really matter? Well, we know that the population distribution of strokes varies with an increase risk in the Stroke Belt in the South. Racially speaking, there does appear to a subtle but real difference in prevalence of prostate cancer based upon ethnicity. Which is why it's so important to look at the participants in any given study to determine whether the data can be generalized to you.
For heart disease, if we're suspicious, we can order a stress test. But not everyone can get active enough on a treadmill and not everyone wants an IV stuck in their arm for a chemical stress test or nuclear imaging, especially not for screening asymptomatic patients in order to catch someone early enough in the disease process when we can make a difference and prevent a negative clinical outcome.
That's where the not-so-new kid on the block, coronary artery calcium scoring or CAC, comes in as it does a great job of predicting heart disease but at the risk of radiation exposure. We like to claim that the radiation is minimal but the truth is that human errors have led to excessive radiation exposure during radiologic imaging.
Since no physical exertion, ionizing radiation or IV is involved, perhaps we should consider using CIMT as an intermediate step between pure risk calculation and CAC scans prior to stress testing & imaging in asymptomatic patients? For now, that makes sense if you're a Caucasian from the Northeast.
Disclaimer: I serve as a medical consultant to HeartSmart Technologies EyeCare Division which markets CIMT to optometrists (whereas HeartSmart IMTplus focuses on the MD/DO segment).
Thursday, July 21, 2011
More Fiber = Lower Diverticular Risk
In a new study published this week in BMJ, analyzing data from the ongoing European Prospective Investigation into Cancer & Nutrition (EPIC), the authors followed 47,033 participants for 11+years, 15,459 of who self-reported as vegetarians. When all was said and done, vegetarians had a one third lower risk of hospitalization for and death from diverticular disease.
So choose wisely. Eat the colors of the rainbow every day, including at least 5 servings each of fruits & vegetables to minimize your risk for diverticular disease and death.
Wednesday, July 20, 2011
How to Prevent Alzheimer's Disease Part 2
Tuesday, July 19, 2011
No Such Thing as a Free Lunch
In an ideal world, we'd only need to swallow a risk-free, side effect-free, interaction-free pill just once and never have to worry again about whatever condition we were treating. To date, we're not even close to reaching that goal. There is no such thing as a free lunch.
We can provide up 10 years worth of protection against tetanus, diphtheria, and pertussis but this requires an injection. Screening colonoscopy is recommended starting at 50 years of age in low risk patients, but there is still a small but real risk of perforation. The statins are extremely powerful at lowering cholesterol but at the risk of myalgias and liver irritation.
This much we've known for a while. We've also theorized that by shrinking the prostate, we might be able to prevent prostate cancer, which then lead to the Prostate Cancer Prevention Trial (PCPT) and the Reduction by Dutasteride of Prostate Cancer Events (REDUCE) trial, both of which did demonstrate an overall 23-25% reduction in prostate cancer. However, the flip side is that both trials also demonstrated an increase risk of high grade prostate cancers. After PCPT and before REDUCE, we tried to explain this by any number of statistical models. However, with both studies arriving at the same conclusion, the FDA's advisory panel denied the claim for chemoprophylaxis last December after concluding that one additional case of high-grade prostate cancer would be diagnosed for ever 150-200 health men treated long-term with a 5ARI.
The FDA has left open the option to continue to treat men with symptomatic BPH and/or hair loss with 5ARIs. But last month, the FDA updated the Warnings & Precautions section with the above discussion & concerns as noted in this week's NEJM (thanks to Dr. Peter G's keen eyes). It's now up to us to deliberate whether the risk is worth the benefit in this specific situation for each individual we see. It would be all too easy if we could foretell the future but unfortunately, my crystal ball is at the repair shop. For now, we'll need to discuss/warn our patients who need something besides an alpha blocker to treat their BPH. Remember, there's no such thing as a free lunch. And there are no risk free, side effect free, interaction free medications.
Monday, July 18, 2011
Caught Between A Rock And A Hard Place - Part 4
What's interesting is that aspirin is also a member of the NSAID class yet it gets a pass and multiple studies have demonstrated benefit in preventing deaths, heart attacks & strokes (although there is a small but real risk of hemorrhagic stroke & major bleeding). Far be it for me to be able to explain why this is. We've attempted to cull the benefit of aspirin and separate it from its pitfalls by developing Cox 2 inhibitors, a subclass of NSAIDs. However, of the many Cox 2 inhibitors that reached the market at the beginning of the century, only one remains on the market, and even that one, celecoxib, has lost much of its glow.
These results aren't just due to chance but you're looking at "only" 5 extra deaths per 1,000 patient-years. We already know that NSAIDs are hard on the kidneys, increase blood pressure and your risk of gastrointestinal bleeding & intracerebral hemorrhage. It's up to you to decide if chronic pain control is worth the potential for an increase in all-cause mortality if you also have high blood pressure & heart disease. Remember, this is currently just an association, not a proven cause & effect.
Sunday, July 17, 2011
Saturday, July 16, 2011
Friday, July 15, 2011
Health Care Reform: Revamp Reimbursement
Granted, most of us went to medical school because we wanted to make a difference for the better. Most of us did not go to medical school to get rich (although getting paid for our efforts was an added benefit). However, somewhere along the way, starting with our indebtedness, we realized that specialists who perform procedures are remunerated dramatically more than generalists who don't perform procedures.
In fact, it's been demonstrated that generalists perform quite a bit of work each day that goes unpaid: make 24 telephone calls to patients, specialists, pharmacists & insurance companies; write 12 prescriptions (in addition to all those written during a patient visit); read 20 lab reports; review 14 consultant reports; review 11 imaging reports; and write/send 17 emails interpreting test results, consulting with other physicians, and/or advising patients. I'm sure the specialists' day is no different or less hectic.
Yet, when it comes to remuneration, the specialist has a significant advantage over the generalist: procedures. Economics 101 defines marginal revenue as the additional income derived from selling one more unit of a good above that necessary to cover overhead. So while most physicians do not consciously perform procedures with marginal revenue in mind, the way our remuneration system is set up, it's difficult to ignore as these procedures are priced at hundreds if not thousands of dollars. On the other hand, for generalists to squeeze in an additional patient, we're looking at marginal revenue measured in tens of dollars per patient visit. Plus now, we face the wrath of those patients kept waiting who now want to bill us for their time.
Don't get me wrong. I'm not saying we shouldn't be paid for what we do. But I think we need to minimize the disparity in remuneration between generalists & specialists. Also, let me be absolutely clear and point out that the majority of the inappropriate procedures occurred in a minority of facilities authorized to perform them. In other words, most physicians are trying to do the right thing, whether they're specialists or generalists.
Our Largest Export: Our Leading Causes of Death Part 2
Just over 2 weeks ago, I commented on how one of our leading exports was our leading causes of death. Now, of course, one can't export death, well not in the sense of heart disease, cancer, stroke & lung disease. However, when we are looked at as the model of success (at least by most aside from the Middle East), it stands to reason why non-industrialized cultures to emulate our lifestyle. After all, Coca-Cola, McDonald's, and Marlboro are some of the most well recognized brands around the world.
Just as I try to teach my oldest son to be a better example for his younger siblings, industrialized nations should attempt to provide a better example of how to eat in a healthy manner for our non-industrialized neighbors. Too bad, it's less expensive to eat poorly and more expensive to eat healthily.
Thursday, July 14, 2011
Please Help Me! I Just Lost My Job and Can't Afford . . .
I've lost track of how many times I've heard that phrase. Despite what the government keeps saying, I'm not convinced that we're better off now compared to before. Many individuals & families remain devastated by the recent economic downturn. As a result, they've lost their health (and dental) insurance, including medication coverage. Luckily, there are options for those down on their luck.
A list of free or low cost medical clinics can be found at
http://www.freemedicalcamps.com/. This listing includes free dental clinics, too. Federally funded health centers can be found at http://findahealthcenter.hrsa.gov/Search_HCC.aspx. These facilities are mandated to care for you, even if you don't have any health insurance. Instead, you're asked to pay what you can afford, based upon your income.
By the way, guess who provides the vast majority of care at all these clinics? Family docs! Tell your Congressperson that we need more funding to train more family docs, especially if they intend to expand the number covered by insurance. It doesn't do any good to give more people insurance if you don't have enough physicians to care for them.
http://www.freemedicalcamps.com/. This listing includes free dental clinics, too. Federally funded health centers can be found at http://findahealthcenter.hrsa.gov/Search_HCC.aspx. These facilities are mandated to care for you, even if you don't have any health insurance. Instead, you're asked to pay what you can afford, based upon your income.
By the way, guess who provides the vast majority of care at all these clinics? Family docs! Tell your Congressperson that we need more funding to train more family docs, especially if they intend to expand the number covered by insurance. It doesn't do any good to give more people insurance if you don't have enough physicians to care for them.
Many older, generic medications are available for $4/mo or $10/90d and can be found at many big box chains, chief among them Kroger, Target and WalMart.
As much as we tend to malign Big Pharma, they do make an attempt to assist those who cannot afford their new & branded medications. You can search for those drugs that aren't available generically at
Of course, you're then left with expensive lab tests. Never pay retail for anything. Check out some of these (lower cost) options
Good luck!
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