Thursday, June 30, 2011

Prostate Cancer & Smoking

Do you really need another reason to stop smoking?  If you're a male smoker closing in on retirement, check out a study published in JAMA last week concluding that smoking increases all-cause, prostate cancer specific, and cardiovascular mortality.  One has to have quit for at least 10 years for those mortality figures to drop back to baseline non-smokers' levels.

Just how strong is the data?  Well, the authors followed 5,366 men from the Health Professionals Follow Up Study who'd been diagnosed w/prostate cancer.  This prospective observational study included those diagnosed between 1986 & 2006 so the statistics are reasonable and random chance is very unlikely to account for these findings.

The bottom line for you & me?  Don't smoke!  And if you do, now's the day to quit.  If you need help, ask your family doc.  Good luck!  And don't give up!

Wednesday, June 29, 2011

Our Largest Export: Our Leading Causes of Death

One's health is a very individual & personal issue yet taken as a whole, health is also a public matter given the large amounts of money we spend annually.  Here in the States, we recognize heart disease, cancer, stroke & lung disease as our perennial leading killers.

We think of infectious diseases as the biggest issue in the rest of the non-industrialized world.  Yet as I pointed out almost 2 months ago, India will soon need more cardiologists than infectious disease specialists.  In fact, the United Nations gave a conference last week to preview an upcoming conference on noncommunicable diseases.

And in a summary report released last month, the UN noted that noncommunicable or chronic diseases accounted for almost two-thirds of world-wide deaths in 2008.  This number is only expected to increase and disproportionately so in developing countries amongst lower income populations.  Globally, cardiovascular disease (including heart disease & strokes), cancer, diabetes & lung disease account for the majority of this silent epidemic that has snuck up on us.

The causes?  Tobacco use, unhealthy diet, lack of physical activity, and harmful alcohol use are responsible for more than three-quarters of the deaths in these 4 categories.  Their commonality?  All are within our power to change in order to prevent disease.  We just have to have the stomach to make & enforce legislation in the name of public health.  Why?  Because as individuals, we don't have the personal willpower to make the right choices.  And society is then left to pay for our errant ways to the tune of $300B worldwide in 2010 for cancer and $400B wordwide for lung disease.  Either we change, Big Brother makes us change, or we all go broke.

Tuesday, June 28, 2011

EHR vs EMR vs PHR?

During my time at the Brody School of Medicine, we transitioned from the Stone Age of paper charting to the 21st century of using an electronic medical record (EMR).  Nowadays, we're supposed to call it an electronic health record (EHR) which is supposed to encompass so much more (?).  When I made the decision to leave my employed position and start my solo practice, I also decided that I would start using an EHR right away.  (DISCLAIMER:  I am serving as a guest speaker today to answer questions regarding Practice Fusion's EHR).

Why?  Especially since I have no (federal financial) incentive.  Simply because it makes sense for me to have access wherever I might be for my patients' benefit.  Therefore, I am no longer limited to & tied down by a traditional brick & mortar office in providing optimal care to my patients.  Instead, I can now access their records from any place on this globe w/reasonable Internet access (as I learned earlier this month, this excludes the Disney Wonder plying Alaska's Inner Passage).

But what's a PHR?  Personal health record.  It's the patient's record from his/her perspective.  The problem is that it's typically patient initiated.  This is where health care literacy comes in.  And motivation.  Which is why Google Health is about to shut down as announced in the Wall Street Journal last week.  Not enough of us are motivated to think ahead to put our health information online for that just-in-case moment, much less keep it up-to-date w/each doctor's visit.  We're still stuck in the Stone Age carrying around little scraps of paper with out-of-date drug names scribbled in fading ink.  Good luck to your emergency physician who tries to figure which blue pill you're taking (and no, it's not that one!).  

The solution?  If you're lucky enough to have a physician who uses an EHR, ask if you can have access to its PHR portal.  And if you're a physician who's keeping up with the times (whether due to the carrot or the stick), consider offering your patients access to their records, perhaps even a (paper or electronic) copy of your/their chart note.  After all, what do we have to hide?

Monday, June 27, 2011

Exercise Intensity: Does It Really Matter?

Everyday, we implore our patients to become (more) physically active.  Most recommendations are for 150 minutes/week of moderate intensity exercise or 75 minutes of high intensity exercise.  If you're (chronically) short on time, then high intensity exercise seems to be the way to go.  But it takes a lot of discipline to engage in physical activity at this level on a regular basis.  

What if we had more incentive to exercise at high intensity?  Wouldn't it be nice to know that there's a result from high intensity that can't be achieved w/moderate intensity exercise?  In fact, as Dr. Michael M pointed out to me, a re-analysis of the Northern Manhattan Study was published in Neurology two weeks ago in which the authors concluded that high intensity exercise was associated w/less silent brain infarcts or subclinical cerebrovascular disease.

They arrived at their conclusion after performing brain MRIs on 1,238 clinically stroke-free individuals average age 70yo and found 197 w/silent brain infarcts.  After adjusting for the usual variables and going  thru the typical statistical machinations, the authors concluded that those individuals who engaged in physical activity in the highest quartile of intensity as measured by metabolic equivalents (METs) were almost half as likely to have subclinical cerebrovascular disease as those in the lowest quartile of intensity.

What are the implications for you & me?  Well, let's first remember that this is/was an observational study.  Therefore, it's good for generating hypotheses but it does not prove cause & effect.  Second, it's intriguing to note that it's not the only study to support a greater threshold for exercise than we currently recommend.  So while any exercise is better than none at all, this study begs the question whether protecting our brain might require greater intensity than preventing heart disease.  Third, as for applicability, the Northern Manhattan Study includes women & Hispanics, which broadens our ability to generalize beyond our typical Caucasian male.

Lastly, let's not forget that this study looked at silent brain infarcts.  While subclinical cerebrovascular disease has been linked to impaired mobility & falls, cognitive dysfunction & dementia, and initial stroke & death, this study makes no statement as to these clinical manifestations, unlike the headlines in recent news publication.  So stay tuned for more to come!

Dark Side of Statins

HMG coenzyme A reductase inhibitors, commonly known as statins, have become the darling of the medical world in the relatively short amount of time since their introduction due to their ability to reduce LDL-cholesterol (the bad variety) with increasing effectiveness and more importantly, to lower the incidence of heart disease.

However, statins are not without their dark side.  Witness the fiasco that was Baycol, an incredibly efficient drug at lowering cholesterol but deadly when used in combination with gemfibrozil.  Unfortunately, we physicians tend to ignore product insert warnings and sometimes even black box labels such that the FDA pulled Baycol off the market in 2001.

More recently, a commentary was published in the New England Journal of Medicine regarding the increased risk of myopathy & rhabdomyolysis when comparing high dose (80mg) simvastatin to lower doses of the same drug.  And while there has been a movement to chose initial statin doses based upon the required percentage lowering necessary to achieve LDL goals, the FDA is now advising that 80mg of simvastatin no longer be used for initial therapy.  Thus the FDA changed the labeling such that high dose simvastatin should only (continue to) be used in those who've tolerated it for over a year.  In other words, anyone who needs greater LDL lowering than can be achieved w/40mg of simvastatin is advised to use something else to achieve his/her goals.  

In another knock against statins' previously pristine reputation, a meta-analysis of 5 trials was published in JAMA last week concluding that intensive, high dose statins are associated with an increase risk of diabetes.   This finding is consistent with a previous meta-analysis of 13 trials published in Lancet last February.  The point of this post is not to stop using statins but to be aware of their potential side effects.  As always, we need to weigh the risks versus the benefits for each individual.

Sunday, June 26, 2011

Q&A Session at

Best treatment for diabetic neuropathy pain?

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Do you have to be "knocked out" to have a concussion?

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Inflamed Liver, possible Liver disease, looking for a healthy diet/exercise plan to rejuvenate the liver.

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how can my stomach be flat?

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Is there any treatment for frequently recurring outbreaks of cold sores?

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Why do I keep falling?

Saturday, June 25, 2011

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i have itchy red bumps on my legs and arms and thighs

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How can I lower TSH levels naturally, without medication?

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im really worried as i have red spots on my vagina and bum. They really sore and im really scared of wot it could be?

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I am getting over a bad cold and I have two sores on the inside of my upper lip. They are white and tiny. What are they and how

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What shall I ask the Nuero Doctor?

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Dizziness after gas comes up.

Friday, June 24, 2011

Just One More Thing: RIP Peter Falk

In a demonstration of its ubiquity, Alzheimer disease just robbed us of another wonderful actor, Peter Falk, who died yesterday.  I can still remember while growing up how I sometimes got to stay up late to watch him play the forgetful cigar chomping Columbo.  Oh how my parents loved that show.  I enjoyed him a second time as the loving grandfather in The Princess Bride.

In a sad commentary, his daughter and 2nd wife apparently got into a legal brouhaha over his conservatorship.  This occurred after his daughter went public w/his diagnosis just over 2 years ago.  I bring this up to point out how important it is for us to get our legal & financial house in order before we think we need to do so due to some medical condition.  This is a point of prevention so very rarely discussed.  But by using the late Mr. Falk and his family as an example, this would be the perfect introduction to a discussion w/your parents (or your children) to avoid a similar fate.

Antibiotics: Can I Have More Please? Part 3

The biggest surprise I encountered while reading the studies for the past 2 Fridays' posts was a 3rd article from the same Pediatrics journal but this time looking at the link between antibiotics & asthma from a different perspective.  In this particular review & meta-analysis of 20 studies published between 1950 & 2010, the authors found that pre-natal exposure to and early childhood administration of antibiotics was associated with an increase risk of developing asthma, consistent with the hygiene hypothesis.

Just what is the hygiene hypothesis?  Back in 1989, David Strachan theorized in the BMJ, based upon epidemiological data, that hay fever was due to declining family size (thus decrease in antigen transmittal by unhygienic contact w/older siblings), improvement in household amenities, and higher standards of personal cleanliness.  Countless observational studies have since been published supporting some association between early antigen exposure and decreased risk of developing atopic conditions, eg asthma, eczema, etc.  The theory isn't airtight but it is intriguing.

We still don't have any causal data yet to prove this hypothesis, just corroborative evidence that demonstrates a link.  However, I see no need for my children to take antibiotics (unless warranted) perchance I don't stimulate their immune system enough!  After all, it would appear that we may soon add asthma to the list of complications associated with taking antibiotics as enumerated last week.  On the other hand, I'm not a total believer as I still make them wash hands, sneeze/cough into the crook of one's elbow, and get immunized.  

Thursday, June 23, 2011

Eating Potato Chips Leads to Weight Gain

In one of those "duh" articles, USA Today proclaimed "potato chips worst culprit for weight gain".  On the surface, the study published in today's issue of the New England Journal of Medicine begs the question why money was spent on this study.  After all, conventional wisdom states that "calories in equals calories out".  But how do we explain why some Jack Sprats can't gain weight despite eating only fat while their partners can't lose weight despite avoiding fat?  Perhaps it's not so simple & clear cut.

The authors followed 120,877 healthy non-obese men & women for various periods of time from 1986 to 2006.  Weight was assessed every 4 years since we tend to put on excess weight slowly during our middle age.

Weight gain was associated w/potato chips, potatoes, sugar sweetened beverages, unprocessed & processed meats.  Therefore, the old adage to "eat everything in moderation" might not really apply to weight maintenance.  Weight loss was associated with consumption of fruits & veggies, whole grains, nuts & yogurt.  

As expected, lifestyle also impacted weight, eg physical activity, alcohol use, smoking, and television watching.  Sleeping less than 6hrs/night or >8hrs/night was also associated w/more weight gain.

In the end, I'm not convinced that this study presented any new evidence.  We've never recommended eating potato chips, potatoes, sugar sweetened beverages, unprocessed & processed meats, even in moderation.  Likewise, we've always advocated increasing physical activity while limiting television viewing.  It just comes down to applying our knowledge to our daily life.

Testosterone vs Heart Disease

A nice review & meta-analysis was published this month regarding the association between testosterone and heart disease.  While the authors found (only) 19 studies to analyze, they had to search as far back as 1966 all the way up to 2009.  The implication is that we haven't looked closely enough at this linkage and certainly not with adequate statistical discipline.

In fact, studies published prior to 2007 found no association whereas those published afterwards did.  Clearly this raises concern for bias, although it would be difficult, if not impossible, to organize a conspiracy from such a diverse group of researchers.

On the other hand, age appeared to make a difference, as those younger than 70 years of age demonstrated no linkage between heart disease & testosterone.  However, testosterone appears to make a slight difference for those men older than 70.  This then brings up again the possibility that low testosterone reflects poor health which increases one's risk for heart disease, rather than the more recent excitement that low testosterone in some way directly increased one's risk for heart disease.  

The take home point for now is to avoid starting testosterone in hopes of gaining some supposed heart benefit.  Testosterone to treat symptomatic hypogonadism is reasonable but not to overtly prevent & treat heart disease (which hasn't yet been proven).

Wednesday, June 22, 2011

Glen Campbell Admits to Alzheimer Disease

I admit to a certain amount of celebrity voyeurism, just like most of you.  Leafing thru magazines while waiting in line in the grocery store and reading the same while in a professional office are my guilty pleasures.  But it gave me no pleasure to find out today that country music icon, Glen Campbell, just went public with his diagnosis of Alzheimer disease (AD).

Apparently he'd suffered from short-term memory loss for years.  As you know, memory loss that doesn't impact function is the sine qua non for mild cognitive impairment (MCI), approximately 50% of whom will go on to develop AD.  Currently, MCI is a clinical diagnosis as is AD.

As noted in an earlier post, we have recently defined pre-clinical AD whereby the patient is completely asymptomatic but carries biomarkers of disease.  Once we discover biomarkers with good accuracy and predictive value, it will help aid in research for a cure since we can then include just those patients w/AD and exclude those w/o AD from specific clinical trials.

These biomarkers will also help make the diagnosis more clear and aid in understanding the transition from MCI to AD (perhaps the reason that only 50% convert is that the other 50% don't have the appropriate biomarkers and are actually suffering from some other condition).  There's a nice commentary & review of this new concept in last week's JAMA.

My thoughts & prayers go out to Glen Campbell & his family at this time, as well as to all those who either suffer with/from this disease or care for someone who does.  In the meantime, let's do what we can to minimize our personal risk of falling prey to this disease.

Health Care Reform: Medicaid Implications

Far be it for me to claim that I have the (best/only) answer to our health care fiasco.  However, before searching for solutions, we need to know & understand the problem.  Last week, I noted how more primary care physicians (Disclaimer:  I am a primary care physician) improve Medicare beneficiary outcomes at a lower cost. This week, I thought I'd point out a recent study looking at how publicly traded Medicaid managed care plans compare to non-publicly traded ones with regard to cost & quality.

Specifically, the Commonwealth Fund, started in 1918, noted that the publicly traded plans, who answer to shareholders, spent more money on administration, compared to the non-publicly traded ones.  As a result, the publicly traded Medicaid plans also spent less money on actual patient care, eg medical loss ratio.  Of course, money isn't everything.  But in this particular situation, quality of care, as measured by vaccinations, well-child visits, and the usual blood pressure, LDL, HgbA1c parameters, etc fared worse in the publicly traded plans.

The authors were benevolent and offered up explanations for their findings.  For instance, perhaps the larger publicly traded plans had higher administrative costs to handle the greater number of enrollees.  Perhaps they had greater expenditures for information technology.

However, I am not so sanguine.  Just follow the money.  A publicly traded company is beholden to its shareholders, not its enrollees and membership.  My opinion, and it's just my opinion, is that the higher administrative costs are to pay for employees to deny & delay care, thus lowering actual patient care expenditures.  As a patient (I'm human, after all!), my premiums continue to go up.  As a physician, my reimbursement continues to decline.  And in fact, many of my colleagues are forced to hire staff to deal with all the road blocks to care put up by these health plans.

In the end, has your quality of care improved?  Have you gotten out of your plan what you put into it?  Not likely if the CEOs of the major health care plans all hauled in several million dollars in compensation last year!  For instance, Ronald Williams, the exiting CEO of Aetna, made off with $14 million in stock as a bonus on top of $6 million in salary.  That's a lot of money that could have gone towards diagnostic tests, procedures, and therapy.

I guess things could be worse.  I suppose a health care plan could pay its CEO $124.8 million for a year's work.  Don't think this could happen?  How could we so quickly forget United Health's William McGuire remuneration for 2005?

Tuesday, June 21, 2011

Tiotropium Kills (or Does It?)

Several weeks ago, I noted that inhaled anticholinergics can increase men's risk for urinary retention.  Upon rereading my May 27, 2011 post, I realized that I didn't really mention any examples of these inhaled anticholinergics, just the class name.  But the fact is tiotropium, the newest amongst others, has some side effects of which we need to be aware.

But since it makes breathing easier for those patients suffering from chronic obstructive pulmonary disease (COPD) or emphysema, I still thought that I would offer it my male patients and just be more forceful & emphatic in my warnings.

However, in a study published last week, researchers in the UK linked the use of tiotropium mist for COPD to a 52% greater relative risk of death compared to placebo.  Ouch!  My patients can tolerate an increase risk of urinary retention but greater risk of mortality in the 6th leading cause of death?  No way!

Of course I had to dig deeper.  It turns out that in the UK, tiotropium is available in 2 forms:  powdered & mist.  Only the former is sold here in the States but it was the latter that was studied in 3,686 patients randomized to tiotropium vs 2,836 randomized to placebo in an analysis of 5 double blind trials.  First things first.  This study of studies has a reasonable number of subjects.  Second, it's probably not applicable to us here in the States because the version of the drug studied isn't sold here.

But go read the accompanying editorial when you get a chance.  The editorialist does a wonderful job of explaining the difference between relative risk (46% by his calculations) and absolute risk (0.8%).  He goes on to explain that, yes, while one's relative risk is greater as a result of tiotropium, one's overall risk of death is still rare.  We'd need to offer placebo for 1 year to 1,000 patients  in order to harm 18 patients.  And we'd need to prescribe tiotropium for 1 year to 1,000 in order to harm 5 patients.  The number needed to harm calculates out to treating 121 patients in order to harm 1 patient.  So perhaps we don't need to throw out our powdered tiotropium after all (or is that yet?).  As always, we need to analyze more closely what's published in order to get the whole story.

Monday, June 20, 2011

Your TV Can Kill You! Part 3

All the major TV networks are going to hate me for this.  Hollywood, too.  Why?  Yet another study has been published linking television viewing to type 2 diabetes (T2DM), cardiovascular disease (CVD), and all-cause mortality.  And for those of you who like to push the limit, just how much is too much?  Plan to turn off your TV after 119 minutes each day.  Why?  Every 2 hours of TV viewing a day was linked to 176 cases of T2DM per 100,000 individuals per year, 38 cases of fatal CVD, and 104 deaths from all-causes.  In Europe & Australia, it's reported that their citizens watch 3.5-4hrs daily.  Here in the States, we top that by spending 5hrs on average in front of our televisions.

Of course, one could argue, as I have in other posts, that this data is just observational rather than proof of cause & effect.  That's well & true.  But I find it difficult to understand what there is to be gained from this much viewing.  More importantly, what is the harm in spending significantly less time watching television.  So get off your tail, turn off your TV, and go do something.  Like exercise!  And just in case you need more convincing and missed Part 2 . . .

Sunday, June 19, 2011

Q&A Session at

sputum specimen

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my mothers heart rate is 40 (with HBP meds), her right ankle is swollen and she is stating that her lower back is burning. What

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nipple growth

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stomach infection remedies

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I have a vary large oval lump, about 5" in length in my right groin. It can get very hard at times but when I urinate it gets so


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i am 47 with enlarged prostrate and psa 3 what should i do?

Saturday, June 18, 2011

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What do I need to know about caffeine withdrawal?

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Do I have to take caffeine pills to get the benefits?

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Is it dangerous to mix caffeine and alcohol?

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Is there something we can do for sugars of 429 to lower them?

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What is wrong with trying to get my thyroid function from "low normal" to "normal"?

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Re: Chemo, my dad is 80 years old with lung cancer, stage 3, the chemo is killing him. he lost 14 pounds since we started

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I have no job, no health insurance but I need to see a dentist very soon because my gum is swollen and bleeding. Where can I go?

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medical profession

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i was just tested for vitaminD levels. The report said my number was 18 and should be at 40, the docotr wants to give me a

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Chronic Fatigue Syndrome

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Should I see a doctor for a toe that got stepped on?

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How do I stop taking wellbutrin?

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Is it ok to take tylenol while taking coumadin?

Friday, June 17, 2011

Antibiotics: Can I Have More Please? Part 2

As a follow up to last Friday's post about antibiotic prescribing habits, I should mention that the data was obtained from the States.  However, in another study published online prior to its print release this month, Belgium researchers noted similar findings, such that children w/asthma were almost twice as likely to receive antibiotics for an upper respiratory infection (URI) than children without asthma, all other things being equal.  But we've known for quite some time that asthma is more an inflammatory condition than it is an infectious one, right?  And that the majority of URIs are due to viruses that don't respond to antibiotics.  It's nice to know that the US is not alone in overprescribing antibiotics.  

Thursday, June 16, 2011

FDA Places Smokers Between Proverbial Rock and Hard Place

In yet another announcement, the FDA today warned of an increase risk for 2nd heart attack & new peripheral arterial disease (PAD) in smokers who've already had a heart attack and are taking Chantix (varenicline) to help stop smoking.  We've known for quite some time that tobacco use increases one's risk for heart attacks, strokes & PAD.  We've also known for quite some time that those who already suffer from one of the aforementioned are at increased risk for a 2nd similar event and/or new vascular event.  That's why it's so important for smokers to quit smoking and non-smokers to never start (or be chronically exposed to second-hand smoke).

With that said, varenicline does help smokers quit smoking.  But so does bupropion and replacement nicotine without increasing cardiovascular risk (and without increasing suicide risk, yet another strike against varenicline).  But as I mentioned yesterday, don't stop taking any meds abruptly.  Instead, discuss your options w/your family physician.

And don't forget to consider relative risk vs absolute risk.  While those who received varenicline had approximately twice the risk of heart attacks, etc, the absolute risk was only 4 more per ~350 (from 3/350 to 7/353).  Therefore, the number needed to harm (NNH) is 100.  In other words, 100 smokers would have to take varenicline for one year for one to have a cardiovascular event.  You should compare that number to your risk for a heart attack (see both Framingham & Reynolds Risk).

Testosterone vs Heart Failure Part 2

Last November, I wrote about a possible association between testosterone & heart failure (HF).  It must have resonated because that single post was the most viewed everyday, up until last month.  In fact, during these past 6 months, it's been viewed more than twice as often as my 2nd most popular post (regarding exercise & prostate cancer), which itself had more than twice the readership of my 3rd most popular post (regarding how cigarettes can kill you).  Yet, no one has asked me about taking testosterone for their heart failure.  Curious.

In doing some research, I realized that my review last fall left out a small study published in April 2010 of 191 men average age 64 years old w/HF (both systolic w/loss of ejection fraction (EF <40%) as well as diastolic w/preserved EF >40%).  Total & free testosterone along w/DHEA-S were measured prior to following these patients for close to 3 years.

Researchers noted no correlation between total testosterone and New York Heart Association (NYHA) classification & all-cause mortality.  However, free testosterone & DHEA-S were both inversely correlated with NYHA class and all-cause mortality.

But due to confounding factors, the authors could not unequivocally report an association between androgens and mortality since poor health may have begotten the decrease in testosterone.  Remember association does not prove causation.  Nonetheless, I believe this possible link bears close monitoring.  Further details to come . . .

Wednesday, June 15, 2011

Actos (Pioglitazone) Linked to Bladder Cancer

Trying to stay on top of all the information coming out daily is a near impossible task.  It's been likened to attempting to drink out of a fire hose or hydrant.  Add to that an irascible Internet connection via satellite (I even had troubles onboard ship while in Vancouver's delightful Canada Place) and it's painful.

But I was dealing with that miserable satellite Internet connection when the European Medicines Agency announced last Tuesday that they had noted an association between pioglitazone and bladder cancer after comparing over 155,000 French men & women taking some form of pioglitazone to 1.3 million diabetics not given pioglitazone for 3 years.  Two days later, the French government pulled pioglitazone off the market.  The Germans followed suit the next day.

So perhaps it should come as no surprise that our own FDA just announced today concurrence of a possible link between pioglitazone and bladder cancer based upon the same data.  But as with all observational data that is re-analyzed, this only offers an association but no proof of causation.  Thus, while the greatest risk of bladder cancer was noted in those who'd taken pioglitazone for at least 2-3 years, the FDA cautiously added a warning for use greater than 1 year to all product labels. 

What's this mean for you & me?  Before you abruptly stop taking pioglitazone, talk w/your family physician (as always).  What other options do you have?  What's your personal risk for bladder cancer?  If you've had environmental exposure to several compounds associated w/bladder cancer, you might want to consider switching.  Certainly, bloody urine needs further evaluation, especially if it's painless in a smoker.  And in the end, focus on nutrition & exercise as ideal & free risk-free solution to diabetes.

By the way, thank goodness for complimentary WiFi inside the Vancouver International Airport (YVR)!

Health Care Reform: Medicare Implications

In a study published in JAMA earlier this month, the authors analyzed the health outcomes of 5,132,936 fee-for-service Medicare beneficiaries 65 years or older and compared them to the availability of 6,542 general internists and family physicians.  Broken down into quintiles, those who lived in areas with the greatest availability of primary care physicians had few hospitalizations & lower mortality, without any increase in spending per beneficiary, compared to those who had minimal access to primary care.

Given the multitude of issues at play with regards to health care reform, clearly one solution, amongst many, is to increase the primary care workforce.  How do go about doing this?  Decrease the cost of medical education and improve reimbursement for primary care.  It's that simple!

And in a rehash of a highly publicized article that appeared in the NY Times 2 years ago about the cost of care in McAllen, TX, we should also consider not just improving reimbursement for primary care but revamping the whole model whereby physicians get paid for caring more rather than just doing more.  As it stands, we're currently incentivized to do more just because we can, not necessarily because it's in our patients best interest.  Some of this can be blamed on our litigious society but not all.  Read the article if you haven't already.  It's an eye opener.

Tuesday, June 14, 2011

Fish Oil & Clots

Back in the Stone Age when I was an undergrad, we used to think of heart disease as resulting from the gradual stenosis of the lumen from plaque piled upon cholesterol-laden plaque.  Enlightened now after more than 3 decades of research, we now know that acute coronary syndromes occur when unstable plaque ruptures and leads to acute vessel blockage.  That's why we recommend aspirin and other agents especially to those who've already suffered a heart attack and/or had a stent placed - we want to minimize the risk of yet another errant clot.

Well, in a small randomized, double blind, placebo controlled study published 2 months early, authors gave 1g fish oil (Omacor brand consisting of 460mg EPA + 380mg DHA) to 30 patients and placebo to 24 others, all who'd already had a stent placed and were already taking dual anti-platelet therapy.  After just 1 month, the researchers were able to demonstrate a statistically significant difference anti-thrombin (clot) effects.  While this is disease-oriented evidence rather than the patient-oriented evidence that I would prefer, it's definitely something to consider & discuss w/your physician.

Monday, June 13, 2011

Fish Consumption vs Heart Failure

Several aphorisms & sayings came to mind as I reviewed a study published early online last month in order to compose this post.  The devil is in the details.  Don't assume anything because it will make an a-- out of you & me.  Is this a fluke (no pun intended) or trend?  What's good for the goose, is good for the gander (I hope!).

In an(other) analysis of the Women's Health Initiative (WHI), 84,493 women 50-79yo w/o baseline heart failure (HF) were followed for an average of 10 years.  Those who consumed baked/broiled fish >5/wk had a 30% lower risk of developing HF compared to those who consumed baked/broiled fish <1/mo.  However, those who regularly consumed fried fish at a rate of >1/wk had a 48% greater risk of developing HF.

Details, shmetails.  Fish is fish, right?  Wrong?  It turns out that how you cook your fish makes a difference with regards to your HF risk.  Baking & broiling lowers your risk but frying increases it.  

Can we assume that fish oil is the same as fish?  Interestingly, there was no correlation between EPA+DHA levels, fish consumption & HF.  So you better learn to like eating fish!

Fluke or trend?  The latter, mostly, I think.  After all, other analyses have recently concluded that fish consumption lowers one's risk for macular degeneration, heart attack & stroke.  The only flies in the ointment thus far has been a link to increase risk of diabetes & prostate cancer.

Goose = gander?  Remember that WHI consists only of postmenopausal women.  Does this finding apply to premenopausal women?  What about men?  We don't know.

Friday, June 10, 2011

Antibiotics: Can I Have More Please?

As I stumbled thru my daily perusal of the USA Today, I found mention of a study published last month in Pediatrics looking at the unnecessary prescribing of antibiotics in children w/asthma.  The authors noted that from 1998 to 2007, over 60 million medical visits were made for children w/asthma, during which almost 1 out 6 received antibiotics for no other reason mentioned.  Almost half these prescriptions were for a macrolide antibiotic, most easily (often?) written as a "Z-Pak".  Why is it so popular?  It's easy to take (just once daily) and only for a short period of time (just a few days owing to its long half-life).  Unfortunately, what most of us don't realize is that we would've gotten better & recovered during that same span of time even without any antibiotics.

Why?  Most of us are more likely to succumb to viruses than we are to bacteria.  If you think of just the numbers, the odds are totally in favor of viral infection as opposed to bacterial ones.  However, viruses don't respond to antibiotics (and you/we still have to choose a specific antibiotic that is appropriate for the bacterial infection we believe you have).  For an analogy, think in terms of fuel.  91 octane gasoline is a perfectly good fuel but essentially useless in diesel engines.  Both gasoline & diesel are useless in all-electric cars such as the Tesla Roadster (although hybrids like the Fisker Karma & Chevy Volt do sip a bit of dinosaur juice).  For that matter, lipropane & natural gas are wonderful fuels for your backyard barbeque but again useless in most cars (specially made vehicles found at Disneyland, etc, are exceptions).

But aren't we just playing the odds?  We have no easy test to objectively diagnose & differentiate between a viral and a bacterial infection.  So it's often easier to just give in to the parent and move on to the next patient.  However, without proper counseling, we place the patient at risk for allergic reactions, side effects, drug interactions, and unnecessary expense.  Something to think about the next time you're approached for antibiotics for an upper respiratory infection.

Thursday, June 9, 2011

Hypertension: Not Just for the Elderly

As a geriatrician, I focus my efforts on those who are 65 years old and beyond.  As a family physician, I care for any and all without restriction.  However, I don't usually think of hypertension when I see younger patients.  I was reminded of this last month as I participated in pre-participation exams, otherwise known as high school physicals, and had to send a few student-athletes back to their primary care provider with elevated blood pressures >140/90.

Perhaps I wouldn't have been so surprised if I had read the recent results of ADD Health (National Longitudinal Study of Adolescent Health) which found 19% of 15,701 participants 24-32yo to have blood pressure >140/90.  While this could be considered a fluke compared to the 4% finding from 14,252 participants in NHANES III (National Health and Nutrition Examination Survey), both noted similar self-reported hypertension (11% vs 9%).  Mean blood pressure was higher, too, in this new survey (125/79mm Hg vs 114/67mm Hg), consistent with steady increase in obesity.

The longer one has (uncontrolled) hypertension, the greater one's risk for stroke, kidney failure (leading to dialysis and/or transplant), and heart failure.  Thus, the potential implications of ADD Health are tremendous.  First, we need to more aggressively screen & monitor blood pressure, even in our asymptomatic & presumably healthy young.  Second, we need to more aggressively treat those found to have pre-hypertension or hypertension, perhaps not necessarily with medications, but at least with lifestyle modification and close & continued follow up.

Wednesday, June 8, 2011

Health Care Reform: Family Physician Can't Give Away His Practice

The cost of medicine has become so prohibitive that, as documented in the New York Times two months ago, one family physician can't even give away his practice, including solo care of 4,000 patients.

Given the poor reimbursement structure and the heinous regulations under which we practice, not to the mention the thought of our litigious society, no one wants that much responsibility 24/7 with little hope of paying off one's medical school debt as a family physician.

It's no surprise then that many primary care physicians are turning towards alternative & integrative medicine in concierge & boutique practices to get out of the rat race and better support their families and actually participate as a member of the said family.  Or they're starting to add ancillary testing & baseline cosmetic procedures to shore up their bottom line so that they can continue practice medicine.