Wednesday, August 31, 2011

Just Say No!

It looks like I'm not the only one who wrote about the study published earlier this month in the Archives of Internal Medicine about inappropriate colonoscopies.  And I'm not the only one who wrote about the JAMA study about cardiologists performing unnecessary angioplasties and placing stents just a bit too frequently.  It turns out that Newsweek put out a cover story regarding these two recent articles and more, attesting to the lack of benefit demonstrated by much of the advice we dispense daily. 

What's really intriguing are the comments at the bottom of the page.  Many of those who wrote in support continued screening because that's how they found their cancer earlier than they would have otherwise.  So I'm glad for them.  But they neglect to understand that most who were screened received no benefit and in fact, some were actually harmed from follow up procedures

On the other hand, I can certainly empathize with the physicians who wrote in about over-testing to ward off the malpractice attorneys.  Yet other physicians admit to over-prescribing antibiotics because that's what patients really want, even after a 15 minute dissertation about the lack of benefit and actual possibility of harm.

So where does this leave those of us in the trenches vs what's promulgated from on high in the ivory towers?  Having made grand pronouncements from on yonder during an earlier time in my career, I now see things from a different light along w/my colleagues.  But that fact is that both sides have good points to make.  Too often we perform procedures unnecessarily.  Too often we perform tests that haven't been proven to have an outcome benefit, just one of improving a physiologic marker.

But in this day & age of quantity over quality, where we need to see more & more patients to meet our ever increasing overhead, too often we cave in to a request for antibiotics for something we suspect is most likely viral in nature because our patients want a pill now rather than to wait a few more days for the disease to take its course.  Just like they want to gain muscle, lose fat, and have a longer, larger erection, all from some magic pill rather than regular exercise & good nutrition.

So maybe the answer isn't to just say no to unnecessary screening & procedures but to also say no to unnecessary antibiotics.  In other words, patients need to stop pressuring us to prescribe the latest & greatest drugs they've just seen advertised on the television.  And for that matter, unnecessary anti-hypertensives, hypoglycemics, and cholesterol lowering agents if we/they can just say no to bad food choices and physical inactivity.

Dietary Supplements: Is the Fox Guarding the Hen House? Part 3

When it rains, it pours.  Remember last Friday's post about a recent Men's Health article regarding contamination issues due to lack of 3rd party oversight of dietary supplements?  Well, over the weekend, the New York Times published their expose of a few bad apples in the barrel.  


However, those that promise to pack on muscle, strip away fat, and improve/increase erectile function are probably the ones most likely to be contaminated as we search for short cuts to avoid the hard work of exercising regularly, eating nutrient-dense foods, and getting healthy.  As long as we continue our quest for a miracle pill, we remain vulnerable to injury from those who would separate us from our hard earned dollars as quickly as possible in this miserable economy.  Caveat emptor!

Dietary Supplements: Part 2
Dietary Supplements: Part 1

Tuesday, August 30, 2011

Eat More Chocolate!

Hot on the heels of my post last Thursday about eating (dark) chocolate to lower your cholesterol, the results of a meta-analysis were presented to the European Society of Cardiology yesterday and simultaneously published in the British Medical Journal, concluding that consumption of chocolate was associated with lower risk of cardiovascular disease and stroke.

Of course, some of the news agencies misrepresented the findings in their headlines as "Chocolate lowers heart, stroke risk".  Sure it's semantics, but in the case of medical research, there's a world of difference between associative conclusions derived from observational studies and cause & effect relationships derived from randomized controlled studies.

In this particular situation, the authors had to sift through 4,576 references to obtain 7 studies that met all their inclusion criteria, leading to a population of 114,009 participants followed for 8-16 years in 6 cohort & 1 cross sectional study.  More telling is the fact that none of these studies were randomized controlled trials, so all the data is observational in nature and thus any conclusions derived can only be used to generate hypotheses.

Of course, to make matters more difficult, each study used its own measure of chocolate consumption.  Worse, there was no differentiation between dark, milk and white chocolate, much less cacao (cocoa) content.  Therefore, the authors could only analyze greatest consumption vs least with respect to cardiovascular disease and stroke risk, noting 37% and 29% relative risk reduction respectively, regardless of the usual confounders, such as sex, age, body mass index, smoking, and other dietary factors, but without any benefit for heart failure.

So what's the bottom line for you and me?  Well, this study is consistent with all the other observational studies extant about which I've posted.  But due to the calorie & fat content, I would suggest moderation in consumption with focus on high quality, high cocoa/cacao content, dark chocolate.  Enjoy!

Monday, August 29, 2011

Insurance Companies vs Physicians: Who's on first?

Does anyone remember the Abbott & Costello routine about "Who's on first"?  There was quite a bit of confusion since Costello didn't realize that "Who" was the name of the first baseman, and not a pronoun used to describe an unknown person. 

I bring this up because I stumbled upon a New York Times article about the insurance maze physicians have to deal with here in the States.  It turns out that a recent study published in the journal Health Affairs documented a four fold variance in the cost of dealing with insurance in Canada ($22K/physician/year) versus here in the States ($83K/physician/year) and a ten fold differential in terms of time spent (<2 staff-hours/wk in Canada vs 21 staff-hours/wk in the US).

Granted many of us are not thrilled with the idea of a single payer system as exists in Canada, the United Kingdom, and elsewhere.  We don't want the long interminable waits for tests & procedures that are accepted as routine by our neighbors to the north.  And who hasn't heard of some Canadian with means who crossed the border to get some test or procedure done sooner than if s/he'd waited patiently in line.  

On the other hand, the idea of healthcare as a right and not a privilege has a nice ring to it.  Of course, I'm not about to offer free plastic surgery and Botox(R) to everyone.  After all, remember that phrase about inexpensive, great and quick healthcare?  Well, it turns out you can only have two out of the three - but at least it's your choice as to which two you want.

Admittedly, I'm not smart enough to have the answer to a policy conundrum that has stumped our brightest minds for years.  However, given the number of insurance companies and their almost infinite plans/products, each with its own rules & regulations, it seems to me (and others) that convincing the insurers to play by the same rule book would simplify matters dramatically, and in doing so, decrease wasted & bloated expenditures to the tune of $27B per year.  

I'm not saying that the various insurers can't offer different plans/products but rather suggesting that they shouldn't make it so difficult to seek reimbursement that we have to hire coding & billing specialists such as Don Self.  Read the NY Times article and consider all the hoops we have to jump through each & every day.  And if we don't dot an I or cross a T, the insurer denies/withholds reimbursement for work we've already completed, often for months at a time.  Now you understand why some physicians (myself included) have (re)turned to a direct pay model and no longer accept insurance.

Sunday, August 28, 2011

Q&A Session at Wellsphere.com


I have a burning pain above the left leg above knee since last 5 years. it has also loose sensation. what is the cause

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both forearms painful, loss of strength, tingly, painful when moving wrist and arm even the slightest. happened after a deep tis

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Q&A Session at Wellsphere.com

I have an inflamed tendon on the side of my left foot. Feels bruised like. What is the best way to get rid of this.

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I have this sharp pain in my chest .

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my husband has a lot of pain in his penis and it has white pimple looking bumps on it what could this be?

Saturday, August 27, 2011

Q&A Session at Avvo.com

Chances of acquiring STD

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Is there another prostate test besides the "digital" one ?

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Hormone replacement therapy for a young woman?

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What’s the lowest effective dose of hormone replacement therapy?

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Is hormone replacement therapy using bioidentical hormones safer than using synthetic hormones?

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Extreme fatigue. Thyroid is ok and Testosterone is low.

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Would viagra help

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I dont know what to do about my genital warts. How can i fix it or makie it go away!

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What does high level psi

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I have a hard spot on my prostate ,do i have cancer

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Psa

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I have one Herbeden- How do I get rid of it and not get anymore Its on my finger

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Based on cbc: wbc: 3.4 low, rbc: 3.62 low high mch:32.2

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My mother is in a nursing home. Why does she throw up after eating meals?

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I am 61 and I walk everyday since July from a mile to 2.50 miles per day. I stretch and drink water before and after.

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For a 12 hr fasting blood test, why no coffee?

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My mother is 78, her spine is deteriorating and she is in constant pain. She is now in a nursing home and is on strong pain meds

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I had a veried blury eyes and a sharp strait pain on the top of my right side of my sculpi t was first time I am 60 yrs

Friday, August 26, 2011

Dietary Supplements: Is the Fox Guarding the Hen House? Part 2

Last month, I wrote about the dietary supplement industry and how we, as consumers, have no guarantee of the (un)labeled contents, due to the lack of 3rd party oversight, unlike the consumption of over-the-counter medications.  As a quick reminder, the Food & Drug Administration (FDA) has no ability to preemptively inspect a product during manufacturing and remove it from store shelves until it has been reported to cause harm.  In fact, dietary supplement manufacturers have no duty to prove either efficacy or safety in what they sell to us as long as their advertisements are worded just so: "This statement has not been evaluated by the FDA.  This product is not intended to diagnose, treat, cure, or prevent any disease."

Unfortunately, consumers are always on the lookout for a shortcut.  No one wants to eat & exercise in a fashion as described by research attesting to the benefits of a healthy lifestyle.  Instead, we'd rather believe the Internet hype and recommendations from some high school kid working at a vitamin store pushing the week's hot item.  Which explains why the industry can market & sell products alleged to help you gain & maintain an erection like a 20yo while losing 20lbs of fat in 1wk, etc.

So I'm glad to know that I'm not the only one with such a jaded perspective.  In Men's Health, the editors recently researched & published a short 4 page expose on the dangers of dietary supplements.  Check it out - it's rather enlightening and frightening at the same time.  Hopefully, it will make you reconsider those miraculous supplements.  Remember, choose wisely!

Dietary Supplements: Part 3
Dietary Supplements: Part 1

Thursday, August 25, 2011

You Can Have Your Chocolate and Eat It Too!

After yesterday's post, it appears that all we need to do to lower our cholesterol without taking medications is to eat change to a vegan diet.  But does that mean we can't have any fun?  Luckily, it turns out that cocoa consumption can help lower cholesterol in a meta-analysis published early this month in the European Journal of Clinical Nutrition.

The authors analyzed 320 participants in 10 trials ranging from 2 to 12 weeks in duration.  Clearly, the results are only as good as the data and ideally, we'd like to study large numbers of individuals for longer periods of time.  Nevertheless, consumption of dark chocolate products led to a 5.9mg/dL drop in LDL (bad) cholesterol and a 6.23mg/dL drop in total cholesterol.  Not too shabby but not quite as impressive as eating a combination of plant sterols, soy protein, viscous fiber & nuts.

But we need to be clear that chocolate (at least here in the States) is not the same thing as cocoa.  Nor is hot cocoa necessarily good cocoa.  To obtain the benefits of cocoa that have been reported in multiple studies, you need to consume high cocoa content chocolate.  So if the first several ingredients listed are some sort of sugar, that particular product isn't something for you to eat regularly for your health.  Instead, you need to look for high cocoa content chocolate, otherwise known as dark chocolate.  The higher the cocoa content the better, but it should be at least 50-60% cocoa.  Just be warned that when switching from milk chocolate to dark chocolate, it requires an adjustment in taste & palate.  The really high cocoa content (70-80%) stuff can be pretty bitter if you're not used to it.

By the way, as an added benefit, the really good stuff also is a reasonable source of dietary fiber, another component of a healthy diet.  So it appears that you can have your chocolate and eat it, too!  Mangia!

PS Neither I nor my family have any financial connection to or benefit from Godiva (or it's corporate owner) or Trader Joe's (I just happen to live close to the latter and like their products and philosphy).

Wednesday, August 24, 2011

Lower Your Cholesterol Without Taking Medications!

There once was a time when it was considered normal to have a total cholesterol of 300mg/dL.  However, like the dodo bird, that time has long since passed.  With the release of multiple studies, starting with the Framingham Heart Study, we've lowered and lowered our target goals.  Initially, our armamentarium was rather limited but gradually, we developed more powerful agents in the fight against cholesterol.  In recent years, statins have become the de facto standard 1st line agent of choice.  However, these statins are not without their limitations and side effects, such that many of my patients have asked about taking something natural, rather than synthetic, something with a better safety profile.

Let me first note that statins are actually a derivative of red yeast rice (RYR).  Given the lack of 3rd party oversight of manufacture & sales of nutritional supplements, I would venture that statins are in fact safer & more reliable than unmonitored RYR, as noted in a study published last October in the Archives of Internal Medicine.  Yet our faith in purportedly natural and organic products continues to overwhelm the evidence of safety and efficacy of our pharmaceutical products.

Lest this become a lovefest for Big Pharma, let me reassure you that I am using this as an introduction into ways to naturally lower your cholesterol as published in a small short randomized controlled trial in today's JAMA.  More specifically, the authors randomized 351 healthy patients w/o baseline heart disease, cancer or diabetes to a specific dietary portfolio of plant sterols, soy protein, viscous fiber, and nuts over 6 months in conjunction with either 2 clinic visits or 7 over this period for time or to a control diet consisting of high fiber & whole grains but without the portfolio components.

Those who increased consumption of plant sterols, soy protein, viscous fiber & nuts noted 13+% lower LDL, equivalent to switching from no statin to lowest dose and then to 2nd lowest (remember that the rule of 6's expects an approximate 6% lower LDL with each doubling of the statin's dose).  Unfortunately, time spent with a nutritionist did not appear to make a difference.  To be clear, the participants in the active arm of the trial had to consume 0.94g plant sterols, 9.8g of viscous fiber, 22.5g soy protein, and 22.5g nuts per 1,000kcal of energy daily. 

As noted yesterday, good nutrition plays a strong part of our health & mortality.  However, this study demonstrates that telling our patients to eat more fruits & veggies might not be enough to lower their cholesterol.  We have to be more specific in the details.  But if they can adhere to these 4 tenets of lipid lowering, they can expect some very impressive results without resorting to statins.

Tuesday, August 23, 2011

Lifestyle: Choose Wisely!

Last week, I went on a rampage and posted several times on the deadly nature of sitting (physical inactivity) and/or watching TV (which is usually performed while sitting!).  The good news is that more physical activity and less TV watching has been associated many times over w/lower risk of death from any cause (all-cause mortality).  The best news is that we need less physical activity than we originally thought to derive benefit, just 15min/d of exercise (although more benefit was associated with more time spent exercising).  However, physical activity is just one tenet of a healthy lifestyle.

In fact, two years ago back in August 2009, a study was published concluding that just 4 factors (not smoking, eating healthy, staying active, and keeping one's body mass index (BMI) <30kg/m2) were associated with lower risk of chronic diseases, eg cancer, diabetes, heart disease & stroke.  From my point of view, one's BMI derives from two of the first three lifestyle choices, eg nutrition & activity.

So in a study published last week, researchers followed 16,958 participants in the National Health and Nutrition Examination Survey III Mortality Study from 1988 to 2006.  Those who engaged in eating a healthy diet, getting enough physical activity, consuming a moderate amount of alcohol, and never smoking, had a lower risk of all-cause, cancer, cardiovascular disease and other cause mortality compared to those who engaged in none of those activities.  Furthermore, each lifestyle choice was independently associated with mortality, and the number of choices, from none to four, was related to the degree of benefit.

In plain terms, those who engaged in all four lifestyle choices had 11.1yrs less all-cause mortality, 14.4yrs less cancer mortality, 9.9yrs less major cardiovascular mortality, and 10.6yrs less mortality from other causes.  Of course this data is observational so one can only develop hypotheses from it rather than demonstrate cause & effect.  Still, I know of no bad things resulting from any (combination) of these lifestyle choices.  Bottom line:  physical activity is a must; but never smoking, eating right, and consuming a moderate amount of alcohol improve your odds and add life to your years (or is that years to your life?). 

Monday, August 22, 2011

Annual Lung CT Scans for Smokers: Good or Bad?

When it comes to medical studies, I can't help but fall back upon that quote often attributed to Benjamin Disraeli by Mark Twain about "lies, damned lies, and statistics".  If you've been following some of my recent posts about number needed to treat, absolute vs relative risk reduction, and clinical outcome vs physiologic markers, it's pretty clear why the American public doesn't trust physicians & scientists very much since our research conclusions tend to vacillate with the wind, based upon how the results are presented.

Two months ago, a study was published in the New England Journal of Medicine that followed 53,454 persons at high risk for lung cancer who were randomized to either annual low-dose CT scans or single view chest xrays and followed for 5 years.  When all was said and done, the authors concluded that annual low-dose CT scans would reduce lung cancer deaths by 20%.

Of course, this news was immediately trumpeted around the world back in November 2010 when the trial was originally stopped as the next great thing to save all the smokers from their self-induced lung cancers.  At the time, all the statistics weren't available as the researchers were still crunching the numbers.  However, that didn't stopped hospitals and others from advertising low cost lung CT scans for heavy smokers, which some critics are now calling a marketing ploy despite one leading specialist claiming that "the data is pretty compelling" in terms of saving lives.

However, when you look at the numbers, 99.5% of those who received annual CT scans received no benefit while just 0.5% (absolute risk reduction) were helped by preventing death (20% relative risk reduction).  In other words, we would need to scan 217 persons to save one person from dying.  On the other hand, 23% of those scanned would have a false positive in terms of a cancer scare; 3.5% would have to undergo an otherwise unnecessary surgical procedure to clarify the false positive cancer scare; and 0.6% of those scanned would suffer a surgical complication.

From the NNT perspective, one in four scanned would receive a false cancer scare, most of whom would should benign changes upon repeat scan.  However, one in thirty would have to undergo an otherwise unnecessary surgery to prove that they didn't have lung cancer.  And finally, one in one hundred sixty one would suffer an otherwise unnecessary surgical complication.  Is this risk really worth it?

And of course, this doesn't even take into account who's going to pay for all these scans . . .

Sunday, August 21, 2011

Q&A Session at Avvo.com

When i pea it burns it only hapens 2 times in the pased year but it last for about 1 or 2 min is this a std or something els

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How do I control night time urination.

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Trouble with getting aroused before sex

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Is there a way to skip the testing for an STD and just get the prescription?

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45 year old husband, no sex drive

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DM II treated w/ Actos x 5+ y; recently learned of bladder cancer concern for long term users

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My sex life is dwindling and it is making me unhappy. I smoke and I am 63

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Dehydration???

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What causes a metallic/burning sensation in the mouth/tongue for 3 months and still ongoing?

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Can toothpaste cause canker sores?

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My mother has a severe pain on the left side of her abdominal

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I am a MD, I graduated from South America, is it possible to practice in another country without my residency?

Saturday, August 20, 2011

Q&A Session at Wellsphere.com

What causes a sunburnt appearance on the torso/upper thighs following a laparoscopy?

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I have some breakthrough bleeding, what causes it?

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i went into the doctor having stomach problems. after a ct scan they said it looks as if my small intestines are trying to twist

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bleeding after falling on my bike seat?

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i finished my period on Aug. 12 & today i started bleeding again only 2 days after my period ended is this normal or might i be

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I have strange marks along my spinal bones, all in a line. there are three of them and each mark is composed of several tiny red

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The tip of my 3rd toe on my left foot is numb and my nail has started dying.. It's a normal colour and everything.. Is this some

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Itchy areola. hormonal?

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are there any test for fibromyalgia? what are symptoms

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wrist pain

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Can a colonoscopy cause IBS?

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Are Trigycerides and Thyroid function related?

Friday, August 19, 2011

Exercise: More is More Part 2

Exercise!  More exercise!  That's all I ever hear, that's all I ever seem to write about these days.  But there's got to be more to life than exercising, or getting physically active, or avoiding TV watching, right?  After all, we're busy running around the rest of the day and need to take some time off to unwind by sitting down to watch a show or two (or catch up w/our friends latest posts via social networking).  Don't we?

So if you're like me (and my kids), you like to push the limit and find out just how far you can go before getting into trouble.  In the case of exercise, standard guidelines recommend at least 30 minutes/d of moderate intensity activity most days of the week in order to accumulate 150 minutes/wk.  Luckily for you & me, in a study just published online in the Lancet earlier this week (see, maybe I won't be late to my own funeral!), some Taiwanese researchers concluded that just half that amount, 15 minutes/day 6 days/week for a total of just 90 minutes/week of moderate intensity activity was associated with a 14% decrease in all-cause mortality, equivalent to 3 more years of life for women to do something else (and 2.55 years for men).

They arrived at their numbers by following 199,265 men and 216,910 women for 8 years (I'll leave it to you to decide whether you can generalize Australian, British & Taiwanese data to your patients).  Interestingly, those who started exercising 15 minutes/d often then increased to 30 minutes/d.  For those compelled to do more, every additional 15 minutes of daily exercise beyond the initial 15 minutes/d reduced all-cause mortality by another 4%.  In fact, 30 minutes/d of exercise extended life expectancy by 3.67 years in women and 4.21 years in men.

Similar benefits were noted regardless of sex, age, and other typical confounders, including the presence of heart disease.  The conclusion of this week's trifecta?  When it comes to TV watching, less is more.  But when it comes to exercise, more is more (although you can still get benefit by initially aiming lower).


Thursday, August 18, 2011

Your TV Can Kill You! Part 4

Occasionally, I'm on time.  For instance, while I was reading up for yesterday's post, I stumbled, not unlike a blind squirrel finding a nut, upon a study published in the British Journal of Sports Medicine this past Monday linking TV viewing to mortality.

No surprise, right?  After all, as I'd noted previously in January and June, several studies have been published, all linking TV viewing to greater mortality.  An Australian study of 8,800 adults followed for >6yrs noted that each hour of TV viewing increased all-cause mortality by 11%.  A British study of 4,512 adults followed for 4yrs noted that all-cause mortality increased by 52% in those who reported watching TV >4hrs/d compared to those who watched <2hrs/d.  A meta-analysis of 3 studies involving 26,509 individuals followed for 202,353 person-years noted every 2hrs of TV viewing increased all-cause mortality by 13%, accounting for an additional 104 deaths from any cause per 100,000 persons per year.

Yet, it's clear that these studies (and more) haven't affected our collective behavior.  Perhaps, the statistics aren't compelling enough.  Certainly when my residents & medical students have a tough time grasping the concepts of number needed to treat, absolute vs relative risk reduction, clinical outcome vs physiologic markers, and observation studies vs randomized controlled trials, I can't expect the average citizen to make sense of it all (no insult intended).

So in this new analysis of the Australian data, the authors concluded that compared to those who watched no TV, those who spent a lifetime average of 6hrs/d watching TV would live 4.8yrs less.  More specifically, each hour of TV watching (after turning 25yo) reduces life expectancy by 22 minutes.  Holy smackeroo, flying mammal!  Is reality TV and all those game shows and night time dramas really worth it?

Wednesday, August 17, 2011

Don't Just Sit There, Do Something! Part 5

A day late & a dollar short.  It's been rumored that I'll be late to my own funeral.  So it's no surprise that thanks to USA Today, I stumbled upon yet another study linking inactivity to mortality - a year after it was first published!  Better late than never!

So what did I miss?  Well, this was a 14 year observational study sponsored by the American Cancer Society involving 53,440 men (avg 63.6yo) and 69,776 women (avg 61.9yo) who were all disease-free at enrollment. These individuals were part of ACS' Cancer Prevention Study II and specifically selected because they did not have a personal history of cancer, heart attack, stroke, or emphysema/other lung disease.  Others from the larger cohort were excluded due to missing information.

After breaking down the individuals into tertiles based upon time spent sitting, the authors noted that those who spent 6 or more hrs/d sitting outside of work had a greater all-cause mortality than those who spent less than 3hrs/d sitting outside of work.  Physically activity as measured & calculated by metabolic equivalent (MET)-hours/wk was also inversely associated with all-cause mortality at a cut off of 24.5MET-hours/wk.  The association remained after adjusting for the usual suspects such as smoking & body mass index. 

So what are we to make of this study, especially in light of my recent diatribes about research & statistics?  Because it's observational, no proof of cause & effect can be made.  Instead, this study can only be used to develop (and support) a hypothesis.  But as I also mentioned, the practice of evidence-based medicine means making the most of what we currently have available to us.  In the particular scenario of time spent sitting each day, less is more.  Consider the alternative (or at least the consequence).  So don't just sit there, do something!  And if you don't believe this study, check out Part 4!

Tuesday, August 16, 2011

Fibrates: Clinical Outcomes vs Lipid Lowering

All through my undergrad, post-bac, medical school, residency & fellowship days, I never understood just how important statistics would be in the practice of medicine.  Yesterday, I expounded on the general concept of number needed to treat (NNT) while two weeks ago, I wrote about absolute risk reduction (ARR) with regards to the use of rosuvastatin.

On a related front, within family medicine, we've been pushing for evidence-based medicine for a while to focus on POEMs or patient oriented evidence that matters as opposed to DOEs or disease oriented medicine. What's the difference?  POEMs are clinical outcomes, eg prevention of cancer, death, diabetes, heart attack, strokes, etc.  DOEs are physiologic or surrogate markers of health, eg blood pressure, HgbA1c, HDL, LDL, PSA, etc.  Unfortunately, we don't have POEMs to cover all conditions, so we're left with DOEs in many instances.

However, in some situations, we actually have DOEs demonstrating either harm or at best, no benefit, yet we continue to offer said therapeutic option.  Fibrates are an excellent case in point.  As a pharmaceutical class, they've been on the market since 1974, yet we have not been able to demonstrate any clinical outcome benefit in 37 years, despite their perfect against low HDL (good cholesterol) & high triglycerides (TG) by raising HDL & lowering TG.  Moreoever, in 2010, the results of the ACCORD-Lipids study demonstrated no benefit in lowering the rate/risk of fatal cardiovascular events, nonfatal heart attacks & nonfatal strokes in diabetics.

Yet earlier this year, a study published in JAMA demonstrated that US physicians are writing for more & more fibrates compared to our Canadian counterparts.  Lest I be accused of picking only on cardiologists & gastroenterologists, I would like to point out that those of us in primary care are equally to blame for not keeping up with the literature and practicing evidence-based medicine.  And in an editorial published in the current issue of New England Journal of Medicine, the authors, who sit on the FDA's Endocrine & Metabolic Drug Advisory Panel, didn't mince any words, concluding that the addition of fibrates to statins in diabetics solely for the purpose of lowering cardiovascular events has not been proven. 

So regardless of the therapy being offered, make sure you understand the evidence (statistics) behind the desired benefit (NNT), be it clinical outcome (POEMs) or physiologic marker (DOEs). 

Monday, August 15, 2011

Number Needed to Treat

As I've attempted to explain in the past, divining the truth and predicting the future is not an easy thing to do, at least when it comes to applying the latest in medical research to your own situation.  When reading the latest headlines from newspapers & journals, we're often buffeted about.  On any given day, we're supposed to do this; the following day, we're not.  A great portion of the blame falls upon our shoulders as, too often, we don't do a good job of explaining observational data vs randomized controlled trials.  The former is only good for developing links, associations & hypotheses but observational data is useless for guidance, no matter how strong or repeatedly we see similar results.  Guidance & proof, at least from a scientific & statistical sense, can only be discerned from randomized controlled trials.

I mention this because over the weekend, I stumbled upon a fascinating website, www.thennt.com, which focuses on randomized controlled trials and calculates the number needed to treat/harm from the available data.  To truly practice evidence-based medicine, we need to be able to explain our recommendations in a fashion that non-statisticians (like myself) can easily understand.  Many of the conclusions at this website run counter to conventional wisdom, mainly due to the number needed to treat, as calculated from the absolute risk reduction, rather than the more impressive relative risk reduction.  There's more information than I can go into in such a brief space, but I would urge you to look over this website at your leisure and reconsider what you're doing to improve your health and that of your patients.


Sunday, August 14, 2011

Q&A Session at Wellsphere.com

my right leg has been swelling up and my knee sometimes my knee feels like its on fire ..then today i notice a dent on my thigh

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I have a half circle spot on my arm that is red at times and other times looks black and it itches from time to time.What could 

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Are swollen lymph nodes in groin area and a late or missed period related?

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hand pain

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After five years of taking actonyl I'm going to stop cold turkey. Should I be quitting slowly? Thanks

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groin pain after hip replacement on June 13th. how long?

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I have dried blood in urine and pain when peeing

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I have heat rash on my but and need to know what would be good to put on it?

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i have frequent urination but of small amount from child hood around 20 times a day ,but i have no problem of feeling thristy

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What is a torn ovary???And does it matter at age 67

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Last week I read an article about Guanfacine helping dementia in Monkeys and recently human tests have begun. My mother was diag

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Dislocated arm

Saturday, August 13, 2011

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need answers to ed problem

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what can i use to make my penis stay hard during sex that is safe off the shelve

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Is there an herbal medication to help sustain an errection?

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I have low libido, no energy, depression, have to force myself to do what I have to do. No joy in anything. What can I do?

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I lost my sex drive and have erection problems. Also my penis was 7 inches and now small, how do I get it back?

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are testosterone vitamins good for you?

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My Mom Was REcently Diagnosed With Bulbar palsey ....

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what would make food not taste good for a 79 year old women

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What could you do to make yourself urinate? On medication but is out pharmacy want have it until tomorrow, but is hurting and

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My sixtyeight year old mother is currently expiercing bleeding from her private area. What does this mean?

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My Friend's mom has been blacking and passing out on and off for almost a year.

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What kind of surgery is suggested for the following symptoms?

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can a person have cancer, but have a normal white cell count?

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WHat should I do?

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I stood up to take a step and my left knee wouldn't hold me up.

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what can a doctor give my mother to enhance her appetite.

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how many mg of vitamin C should I use per day?

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will livalo cause severe leg pains to the point I can hardly walk? I am 67 and have taken 4mg 2 months.

Friday, August 12, 2011

Sleep Apnea vs Cognitive Fxn: Chicken or Egg?

Sleep-disordered breathing is a collection of disorders most typified by sleep apnea.  It is characterized by recurrent (micro)arousals and intermittant hypoxemia.  In other words, individuals who suffer from sleep-disordered breathing wake up many times each night mainly because they're not getting enough oxygen (air).  This is most commonly associated with snoring, although it's actually that blessed silence that's deadly as that is when the patient is struggling to open the breathing passage to get air in and can't, thus the silence.  Typically, the longer the silent pause, the lower one's oxygen level drops, thus disturbing one's sleep just enough to wake enough to change sleeping position and open up one's airway. 

So why is this important?  In men, sleep-disordered breathing has been associated with all-cause mortality and sudden cardiac death.  And in a new prospective study released this week in the Journal of the American Medical Association, the authors linked sleep-disordered breathing with mild cognitive impairment and dementia in older women.  Just how did they do this?  The authors followed 193 women w/o sleep-disordered breathing and another 105 w/sleep-disordered breathing for almost 5 years.  The presence or absence of sleep-disordered breathing was confirmed via a sleep study or overnight polysomnography using an apnea-hyponea index of 15 or greater as diagnostic of the condition. 

Baseline cognitive function was assessed such that all of these individuals had normal cognitive function at the beginning of the observation period.  However, after 5 years time, the authors noted that those women with sleep-disordered breathing had an increased risk of developing mild cognitive impairment or dementia compared to women w/o sleep-disordered breathing.  So this proves the link between the two conditions but more importantly demonstrates that sleep-disordered breathing pre-dates mild cognitive impairment and death.  Unfortunately this still isn't enough to demonstrate cause & effect, similar to the ongoing conundrum regarding the chicken and the egg.  There's remains an alternative thought process that perhaps the brain dysfunction leads to the breathing issue.  The $64,000 question is whether treating sleep apnea & hypoxemia will improve/prevent mild cognitive impairment and dementia.  Time will tell . . .