Thursday, May 31, 2012

Preventing Falls in Our Elderly: USPSTF Gets It Right!

Not to be too harsh on the US Prventive Services Task Force (USPSTF) but they've come under attack the last several years for many of their recommendations which have gone against conventional wisdom: witness the controversy surrounding screening for breast cancer in 2009 and for prostate cancer just last week.  So it's nice to see that conventional wisdom prevailed when the USPSTF published their Recommendation Statement for Prevention of Falls in Community-Dwelling Older Adults online earlier this week in the Annals of Internal Medicine prior to print release in August.  

In fact, USPSTF specifically recommended exercise or physical therapy along w/vitamin D supplementation to prevent falls in community dwelling older adults at increase risk for said falls, including those who've already fallen.  However, the USPSTF also held back and did not recommend multifactorial risk assessment & management in all community dwelling older adults.

In reality, this new statement shouldn't really be a surprise as a systematic evidence review was published close to 18 months ago in the Annals of Internal Medicine in which the authors noted that 16 randomized controlled trials (RCTs) demonstrated a 13% reduction in falls in those patients who exercised or received physical therapy.  A 17% reduction in falls was noted in those given vitamin D in 9 RCTs.

Granted, these may not be large dramatic reductions but every little bit helps when one out of three community dwelling older adult falls each year of whom one in ten to twenty will sustain an injury requiring medical attention, eg fracture, laceration, and/or brain injury.  The statistics are even worse for those who've sustained a hip fracture as one in four won't live past the anniversary of their fall while only one in two will return to their baseline level of function.  Long story short, the demographics are compelling such that we need to do everything we can to prevent falls in the first place in the growing population of older adults.  After all, we don't want to make the proverbial call, "Help! I've fallen and I can't get up!"



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Wednesday, May 30, 2012

Tight Sugar Control Might Not Help Kidney Function

Another one bites the dust
Another one bites the dust
And another one gone and another one gone
Another one bites the dust, eh
Hey, I'm gonna get you too
Another one bites the dust
- Queen, 1980

Back in the day, we would generalize from a study based upon a specific population and apply those findings to the population at large.  Heck, we'd even take epidemiologic observational data and flaunt that as proof of cause & effect.  Well, I'd like to think that we've matured and moved beyond that phase.  

Witness how the Women's Health Initiative (WHI) and the Action to Control Cardiovascular Risk in Diabetes (ACCORD) studies have upended traditional medicine.  Prior to the latter study, we used to advocate lowering blood pressure & tightening glycemic control in all diabetics regardless of severity & duration of disease.  ACCORD demonstrated to us that better glycemic control doesn't improve cardiovascular risk.  And since last fall, we now have proof that lowering blood pressure doesn't prevent 2nd strokes and that better glycemic control doesn't prevent cognitive dysfunction.

So what happened over the Memorial Day weekend?  A systematic review & meta-analysis of 28,065 adults in 7 trials followed from 2 to 15 years was published in the Archives of Internal Medicine in which the authors concluded that while intensive glycemic control reduces micro- and macroalbuminuria, lower HgbA1c did not improve what matters to patients, end stage renal disease and death from kidney disease.  So another one of our vaunted reasons for tight glycemic control bites the dust.

Yes, we test  for microalbuminuria as a marker of kidney function, but patients only really care about avoiding dialysis and death.  In other words, while we made one of our screening markers of disease look better at greater risk of hypoglycemia, we did nothing that affected patient oriented outcomes.  And isn't that our raison d'etre?  Let's use evidence based medicine to apply trial results to the appropriate population to achieve outcomes that matter to them, not the organ system researchers in the ivory towers.



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Tuesday, May 29, 2012

Longer Commutes Are Bad For You! Imagine That!

Unlike my classmates, I didn't get my driver's license until the 2nd half of my senior year in high school.  Then I went to college in Southern California, Riverside to be precise, and discovered a whole new culture that worshipped cars.  Being freed from parental oversight, I drove to numerous places on a whim and a lark, just to get out of studying (small wonder that I graduated!).  I then entered the workforce and joined the hundreds of thousands of drivers on the roads of LA commuting an hour or two to work and then back again 5 days/week. Back in those days, I religiously changed the oil in my car every 3,000 miles since that was the prevailing mantra.  What I didn't understand at the time was that changing the oil every month was a bit frequent as I drove 36,000 miles that first year out and topped 100,000 miles after 3 years.

What's really incredible is that I thought that this much driving was normal behavior and that there wasn't another option to this lifestyle in which I spent upwards of 3-4 hours daily in my car rather than being physically active, eg engaged in exercise.  It wasn't until I went to medical school and found an apartment on the other side of the city all of 10-15min away from the hospital that I understood how crazy my prior life had been.  This was confirmed when my new classmates asked how could I live so far away from the school!  

Only now has it truly dawned on me that I probably wasn't doing myself a lot of good spending that much time commuting, sitting still in LA's notorious traffic.  This was confirmed in a cross-sectional study published earlier this month in the American Journal of Preventive Medicine in which the authors concluded, not surprisingly, that commuting distance was associated w/less physical activity, worse cardiorespiratory fitness, and increase waist circumference along w/metabolic syndrome risk, after studying for 7 years 4,297 adults avg 47yo four fifths of whom were men.  Longest commutes (defined as greater than 20 miles from home to work) compared to shortest ones (less than 5 miles between residence & employment) were associated w/less weekly METs (metabolic equivalents), lower cardiorespiratory fitness, greater body mass index + waist circumference, and higher diastolic blood pressure.

And in case you're wondering, this study wasn't a fluke.  A similar cross-sectional population-based study of 21,088 Swedes published last November in BMC Public Health associated longer commute times w/poorer health outcomes, eg perceived sleep quality, everyday stress, exhaustion, mental health, self-rated health & sickness absences.  The implication of these studies is that we need to look at city planning in an attempt to improve our public health.  We need to give our citizens more time at home (and thus for physical activity) and less time in the car/bus/train.  No one ever said that this would be an easy task.  



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Monday, May 28, 2012

Q&A Session at HealthTap.com

Is there an easy way for a premenopausal woman to fix the problem of no sex drive, or decreased drive?




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Q&A Session at HealthTap.com

Can a man take an estrogen blocker to increase slightly low T levels, or is testosterone the only true way to raise levels?Do some men take only that?




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Q&A Session at HealthTap.com

What is durable power of attorney? Who needs it?




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Q&A Session at HealthTap.com

Testosterone injections? Who needs these?




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Q&A Session at HealthTap.com

Going for a labiaplasty tomorrow! When can I have sex?




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Q&A Session at HealthTap.com

low sex drive?




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Q&A Session at HealthTap.com

What are the effects of women having low testosterone ?




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Q&A Session at HealthTap.com

Is there treatment for low testosterone levels in 70yo man?




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Q&A Session at HealthTap.com

Does the same level of testosterone have different effects in different people?




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Q&A Session at HealthTap.com

I doubt if i really have low testosterone? am i in denial at 60?




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Q&A Session at HealthTap.com

How long would it take to tone my muscles? 50 and single man again !




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Q&A Session at HealthTap.com

Does tai chi help muscle tone?




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Q&A Session at Avvo.com

What causes a woman to urinate before she climax and what can be done to stop it?




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Q&A Session at Avvo.com

What questions should I ask the gyno?




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Q&A Session at Avvo.com

Is it coffee or caffeine that makes my stomach ache?




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Q&A Session at Avvo.com

I have thyroid




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Q&A Session at Avvo.com

Is a Thyroid blood test of 0.87 normal?




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