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.

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 . . .

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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?

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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?

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.  

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 . . .

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.

However, I also have to accept blame as I was at home w/excellent cable Internet access last September when the FDA first announced that they were investigating a possible link between Actos (pioglitazone) and bladder cancer.

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.

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.

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.

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.

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.

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.

Vitamin D & Multiple Sclerosis

Dr. James L recently pointed out a case-control study published last month in Neurology demonstrating an association between low vitamin D & multiple sclerosis (MS) in African Americans.

We've known for quite some time that greater skin pigmentation as well as living in higher latitudes (farther from the equator) is associated with lower vitamin D levels.  So perhaps it wasn't too much of a surprise to find that African Americans w/MS had a lower vitamin D level (29.7nmol/L = 11.9ng/mL) than their controls (36.6nmol/L = 14.7ng/mL).

But what I found frightening is that 71% of controls were vitamin D deficient (<50nmol/L = <20ng/mL) and that 93% were insufficient (<75nmol/L = <30ng/mL).

Now, if this was the first study demonstrating a link between vitamin D & MS, I'd urge caution.  Remember, look for trends rather than flukes.  However, another case-control study published in the same journal this past February offers physiologic plausibility by linking sun exposure & vitamin D levels to central nervous system demyelination.

Furthermore, a twin-twin study published almost 3 years ago offers evidence of a genetic basis for seasonal regulation of vitamin D in those affected by MS.  So, should we all start pumping up our vitamin D levels or at least enjoying the sunshine a bit more with the onset of summer?  Unfortunately, it's still a bit early to make conclusive recommendations based upon associative & observational data.  Remember that we still don't have cause & effect evidence, just the basis for developing a randomized controlled trial.  And don't forget that sun exposure has been linked to skin cancer.  

How to Prevent Colon Cancer

The World Cancer Research Fund International routinely updates its recommendations on prevention of colon cancer.  As of last month, it's newest pronouncement is that physical activity & dietary fiber convincingly decrease risk.  Luckily, we have control over both these factors.  Probable factors to reduce colon cancer risk include garlic, milk & calcium.

When it comes to increasing one's risk for colon cancer, convincing risk factors include red meat, processed meat, body fatness & abdominal fatness.  Attained adult height is also included but we don't have much control over that.  Alcohol consumption is a bit trickier due to less available data for women, but it does appear to increase risk in both sexes.

Don't forget that all the data we have right now is epidemiologic, observation & associative in nature.  We don't have any evidence of causation.  With that said, it's difficult to find anything bad in increasing one's physical activity and eating more dietary fiber.  And don't forget that more garlic means lower likelihood of confronting a vampire, right?

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is there a doctor that can and will write a diagnoses from viewing the medical records?

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IS IT SAFE TO TAKE IODINE PLUS 2 ALONG WITH SYNTHROID?

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Can I use Elevess if I'm allergic to sulfa drugs?

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CAN I GET ALL MY MEDICAL RECORDS MRI XRAYS FROM MY DOCTOR

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insect bite-reaction

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Do chigger bites, or mosquito bites spread when scratched?

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I woke up this morning to two balls behind the earlobe that have formed and they keep throbbing and making me feel tired.

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IS IT SAFE TO TAKE IODINE PLUS 2 ALONG WITH SYNTHROID FOR THE PURPOSE OF SHEDDING SOME EXTRA WEIGHT?

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Do I really need the stress test?

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I went for a checkup and they found microscopic blood in my urine.

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Why did my pee just come out pink?

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why does it hurt when I urinate?

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Can EEMT H.S. cause a rise in TSH score?

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What kind of doc should we find for 87 YO lady in Murrieta / Temecula CA? Any thoughts or referrals?

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My father has Alziemers and he is diabetic. He cut his arm,didn't remember how. The ER wrapped it and referred him to a doctor.

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How low can he weight and still live?

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when was the bsp test done?

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Do you think I should have my 5.1 bleeding cyst removed or try other options to see if it will shrink?

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what is basal atelectasis with hyperinflated lungs

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I was pushing too hard when I pooped and now my anus hurts - should I go to the urgent care?

 

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While calcification can break up ... 

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How can i decrease my antior pelvic tilt on my left side only/? what can i use to even my left leg lenght with my right?

 

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what is the medical management for hematocele ? what is the treatment for hematocele ? what is the nursing care and health edu

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Burning sensation in my anal. What is the cause?

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i have burning in my anal

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WHITE WOULD CAUSE ALOT OF WHITE BUMPS ON INTER THIGHS

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can i eat tomato soup while doing total body cleanse?

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I have gotton my menstrual for two weeks now and notiice its very heavy and has a slight odour and am getting cramp and pain in

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B.C., antibiotics and bleeding when not supposed to be??

 

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just found out my 19 yr old daughter has a cyst on her ovary and she running a fever of 101 is that normal or not?

 

Cell Phone Use vs Brain Fxn Part 2

Earlier this year, I wrote about a study looking at how cell phone use may (or may not) affect brain function.  At that time, there was some concern over a possible change (increase) in glucose metabolism that was of uncertain clinical significance.  More importantly, epidemiologic & observational studies really hadn't demonstrated any strong association.  My, how times have changed.

Earlier this week, the International Agency for Research on Cancer (IARC), an arm of the World Health Organization (WHO), announced that radiofrequency electromagnetic fields, those emitted by cell phones, are "possibly carcinogenic to humans (Group 2B)".  Does this mean that we have to revert to our old wired, landline pay-phones?  Probably not quite yet.

So why the dramatic announcement?  After all, notice that no new trial results were announced, just the opinion of less than 3 dozen guys (and gals, I suppose) who spent just over a week in the south of France to analyze a heckuva lot of (old) data.  More specifically, 31 international experts from 14 countries got together for 8 days to mull over all the existing evidence on cell phone use.  In fact, here's the National Cancer Institute's response to the IARC press release.

Before you (mis)interpret the news media pronouncements as "cell phones cause cancer" - let's be clear, there's no proof of this yet - remember that there are actually 2 stronger/higher classifications than Group 2B (which includes lead, exhaust fumes & chloroform).  For instance, Group 2A consists of 59 agents that are "probably carcinogenic to humans" while Group 1 consists of 107 agents that are "carcinogenic to humans".  In other words, there are a lot worse things as far as cancer goes.

Not only that, but there's been no dramatic spike in brain cancer cases since the development & widespread use of cell phones over the last quarter century.  In fact, only one study out of hundreds weakly associated an increase risk of gliomas with heavy cell phone use (greater than 30 minutes/day for 10 years).  Hardly enough reason to cancel your service plan and pay several hundred dollars in fees.

If anything, I believe the real danger of cell phones results from their (handheld) use while driving, especially to/from those who text & drive.  So go make yourself a safer driver and (possibly) lower your cancer risk by using a hands-free device. And stop texting while you're driving!  By the way, if you absolutely have to text, consider using text-to-voice and voice-to-text apps rather than your thumbs.

My CME Program re Alzheimer's Disease

My parents taught me not to brag about myself but I can't help it this time as I have to admit it's kinda cool to find my name attached to an online CME program sponsored by the American Academy of Family Physicians.  This is the presentation on Alzheimer's disease that I've been giving around the country at various state chapter meetings.

RIP Food Pyramid (1992-2011)

Le Roi est mort, vive le Roi!  Or in this case, the USDA Food Pyramid is dead, long live My Plate!  First Lady, Michelle Obama, just unveiled the latest incarnation of the government's nutrition guidelines.  

Gone is the familiar shape, initially divided into horizontal slabs, supported by a foundation of 6-11 servings of bread, cereal, rice & pasta.  Part of the problem was determining what constitutes a serving size.  

6 years ago, the pyramid was updated to show someone walking up the steps (representing exercise) with the slabs converted into vertical stripes, representing the various food groups.  Complicating this was the fact that there were actually several different pyramids depending upon your sex & age, if I remember correctly.  And that was its problem.  It was too complicated.

So now we have the plate.  Fruits & veggies represent 50% of your intake, with the proportion of veggies slightly greatly than that of fruits.  Grains appear to represent slightly more than 25% of your meal.  And proteins make up the remainder.  Notice that it's not meat but rather the nutrient that's listed, as compared to the food group for the remainder.  That's because you can obtain your protein from sources other than meat.  Plus there's a small round circle representing a glass, I suppose, for dairy.  But no mention of sugars, fats, salt, etc.

I'm sure there'll be lots of controversy.  For instance, Scientific American has already weighed in w/their opinion.  But while there may be arguments over which form of protein is best, why grains aren't listed as whole grains only, etc, let's face reality.  Junk food is like pornography.  To paraphrase Supreme Court Justice Potter Stewart's immortal concurring opinion, I might not be able to define junk food, but I know it when I see it.  My Plate gives us another way to visualize what we should eat but until we can avoid eating junk foods, we'll continue to gain weight.

Health Care Reform: Cost of Medical School

In an ideal world where money grew on trees, perhaps our professional choices wouldn't depend upon potential income vs indebtedness.  Sadly, such is not the case, at least not with respect to the medical profession.  Back in the day when I graduated with my MD from a private school, it was very rare for a newly minted physician to leave school with debt greater than $100,000.  Of course, this figure dates me as the average medical student graduated in 2009 with over $141,000 in debt - one school booted its graduates out the door owing close to a quarter million dollars on average!

Given the vast differential in potential lifetime earnings, it's not difficult to see how our current payment system, which favors the proceduralist over the primary care physician, might influence one's choice of residency training.  And let's not even consider that for the next 3-7 years or more of residency and possible fellowship training, these physicians will receive a mere pittance (granted $48,460 is more than average income in the US in 2010) after factoring in hours worked (now currently limited to just 80 hours/week!) while their debt increases geometrically.

How can I make this statement?  It turns out that few of the most expensive medical schools are ranked or considered supportive of primary care.  So if we agree that we need more primary care physicians, one place to start is the cost of graduate medical education.

In fact, the NY Times published earlier this week some thoughts from physicians who've left private practice for policy making on how we might actually make medical school free.  I thought I'd mention additional commentary from both a subspecialist (cardiac electrophysiologist) and someone in primary care (internist).

AIM-HIGH Hits Low & Misses Target

Thanks to Dr. Peter G for pointing this out to me.  Last Thursday, the National Institutes of Health and its National Heart, Lung & Blood Institute announced the premature stoppage (18 months early) of its Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health (AIM-HIGH), aimed at studying the effect of 2,000mg daily of Niaspan brand of niacin in those patients with optimized LDL cholesterol (40-80mg/dL) on simvastatin +/- ezetimibe.  The 3,414 participants followed for 32 months were 64yo on average w/most also having diabetes, heart disease & hypertension.

Several thoughts came to mind as I read over the scarce information available in their press release.  First, don't assume anything.  As we were taught in medical school, assumptions make an a-- out of you and me (if you don't get this, look carefully at the spelling of assume).  So while heart attack risk has been inversely correlated to HDL in those w/optimized LDL, there have been no studies demonstrating any benefit from purposefully raising HDL.  Again, we only have observational data but nothing causative.

Second, just because it didn't work in this instance doesn't mean it won't work in another.  Now, I'm sure that will be the spin from Big Pharma.  But in fact, we've had to learn the hard way from studies like Women's Health Initiative and others that what's good for one specific group can't always be generalized to the public.  So perhaps, using niacin to raise HDL doesn't work in those w/pre-existing disease but might work in those without.

Third, perhaps they didn't raise HDL enough.  But that's pure speculation & BS on my part.  The press release reported that HDL was raised 22% on average but it didn't mention baseline HDL.  This was just a press release and, as such, has not been published in a peer-reviewed journal.  However, with a bit of sleuthing, I was able to find a description of the trial which noted inclusion criteria if HDL <40mg/dL in men & <50mg/dL in women.  With observational data, we tend to consider HDL normal when it is 40-59mg/dL, which implies average risk of heart disease; HDL is considered cardioprotective when >60mg/dL so perhaps we shouldn't have expected any benefit since HDL would only have increased from 39mg/dL to 47mg/dL at best.  Only time will tell when the complete data is published.

So what are we to do at this point?  Especially considering a slight increase in ischemic stroke . . . As always, do your research and have an in-depth conversation with your family physician so that you can make a decision that is best for your individual situation.