My 2 Cents

Saturday, May 11, 2013

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Q&A Session at HealthTap.com

My legs start to tingle then become weak and can't move lasts for no more than a minute?

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Friday, May 10, 2013

USPSTF vs ACP vs AUA: Alphabet Soup re Prostate Cancer Screening w/PSA

Want to see a bunch of physicians get in a fight? Ask them for their opinion regarding screening for prostate cancer, especially their views regarding use of prostate specific antigen. Exactly a year ago, the US Preventive Services Task Force came out against PSA-based screening for prostate cancer in all men, regardless of age. I led a discussion on this topic during the American Academy of Family Physicians' Geriatric Medicine conference last month in Santa Ana Pueblo, NM and boy did it get heated.

I think the best way to describe the interaction was an agreement to disagree between those who had an experience with prostate cancer, either personal or family, vs those who had not. The former tended to come out in favor of doing some sort of screening, even using the imperfect PSA, while the latter felt just as strongly about the USPSTF guidelines, especially given all the possible complications once screening is started for a disease that most men will die with, not from.

Of note, USPSTF comes out rather strongly, almost heavy handily against screening, not even making any suggestion to discuss risks, benefits & alternatives with one's patients. Just prior to the conference (but after the presentation deadline had passed), the American College of Physicians published early online in Annals of Internal Medicine their clinical guidelines suggesting that physicians inform 50-69yo men of the risks, benefits & alternatives to screening for prostate cancer. The ACP did not recommend screening average-risk men younger than 50yo or older than 69yo. Furthermore, the ACP also did not recommend screening those with life expectancy less than 10-15yrs.

Most recently, the American Urological Association tossed their hat into the guideline arena but in a very nuanced fashion. The AUA recommends against screening w/PSA in men younger than 40yo but "does not recommend routine screening" in those 40-54yo. And for men 55-69yo, the AUA "strongly recommends shared decision making". In those who still desired screening, the AUA also came out in favor of testing every 2 years rather than annually.

So what are we supposed to do? Make no mention or offer at any age? Set aside even more precious time to discuss the above in detail? And if the latter, at which age group would you start? There's no single right answer for every provider so read the guidelines for yourself and come to your own decision.

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Thursday, May 9, 2013

A Blood Vessel Is A Blood Vessel Is A Blood Vessel Is A Blood Vessel Part 2

Just 2 months ago, I commented on a study linking heart disease to stroke risk. Well, in a cross-sectional study published early online last week prior to print next month in Stroke, the authors concluded that cardiovascular risk was linked to worse cognitive function. What's surprising in this analysis of data from 3,778 participants 35-82yo w/avg 54yo w/o baseline heart disease or stroke that this association was found as early or young as in the 35-44yo class.

While we normally think of dementia as a disease of the elderly, it would appear that our heart health is related to our brain health. When you think about this, it makes sense because both the heart and the brain require adequate blood flow, which can be affected by age, gender, diabetes, tobacco use, blood pressure (and use of BP lowering medications), and total & HDL cholesterol. Of these factors, age, diabetes, smoking & HDL cholesterol had the strongest link to cognitive function.

So don't wait for the inevitable. Take charge of your life now. Choose to eat right & get active. Stop smoking. And optimize your sugar, blood pressure & cholesterol. Investing in your health now will pay major dividends later on.

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Wednesday, May 8, 2013

Vitamin D vs Heart Attacks: Too Much of a Good Thing?

Currently, vitamin D is enjoying its 15 minutes of fame in the limelight. Its deficiency is being linked to just about any imaginable condition. Unfortunately, we only have repeated proof or evidence to support its use in making bones stronger. Severe prolonged vitamin D deficiency leads to rickets which is then cured by consuming vitamin D. But as for its links to dementia, diabetes, heart disease, stroke, etc, the associations are tenuous at best, falling far short of the randomized controlled trial that proves cause & effect.

Therefore, it shouldn't come as a surprise in a retrospective study published in this month's Journal of Clinical Endocrinology & Metabolism, that a U shaped curve demonstrated an increase risk for acute coronary syndrome (heart attack) & cardiac mortality in those w/25OH vitamin D less than 20ng/dL. Interestingly, the sweet spot for 25OH vitamin D was just 20-32ng/dL, with any level about 32ng/dL also being associated w/ACS & cardiac mortality. Of course, the editorialists had a field day picking apart the study.

Bottom line: make time to read the paper especially its U-shaped curve as well as its accompanying editorial (which views the same curve as being more J-shaped in nature) before making any decisions. Leave your mind open to new (interpretation of) data. And avoid listening to those 30 second sound bites that poorly summarize complicated studies.

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Tuesday, May 7, 2013

Testosterone vs Insulin Resistance

Disclaimer #1: Beware of my biases as I write this blog based upon what I find interesting & newsworthy.
Disclaimer #2: It's always better to wait for a study to be published in a peer-reviewed journal, rather than just running with the data based upon an abstract presentation at a conference.

But with that in mind, this abstract was just presented at the American Association of Clinical Endocrinologists' annual meeting this last week in Phoenix, AZ. Before I go on, let me give you a few caveats, specifically what this abstract doesn't recommend. The authors are not recommending that we test all men for hypogonadism. Furthermore, they are not recommending that we put testosterone in the water.

Rather the authors in this small study of 39 hypogonadal men compared to 42 "normal" men, aside from their Type 2 diabetes, randomized to 250mg of intramuscular testosterone every 2 weeks vs placebo for a total of 6 months demonstrated improvement or decrease in insulin resistance in those who received testosterone. Yes, there were some issues, but overall, in those hypogonadal men who received testosterone, benefit exceeded side effects & untoward events.

While this certainly isn't standard of care, there's no reason that we can't ask about symptoms of hypogonadism as a link w/diabetes has been demonstrated in the past. And other studies have demonstrated improvement in hypogonadal symptoms as a result of treatment. But as always, keep a close eye on your patients. And remember that this isn't a DIY project.

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Monday, May 6, 2013

Liptruzet: No Better than Generic Atorvastatin Alone

Don't you love irony? The pharmaceutical industry news was dominated this past Friday by news of the Food & Drug Administration's approval of Merck's Liptruzet, a combination of generic atorvastatin (formerly sold under the brand name of Lipitor by competitor, Pfizer) and ezetimibe (Merck's cholesterol absorption inhibitor sold by itself as Zetia) for use by those with high cholesterol.

Typically, the FDA approves a drug because it offers some benefit over current treatments. At other times, the FDA approves a drug because it offers an alternative to current treatments. I guess the FDA chose the latter because in each article I read regarding this new drug, it's clearly mentioned that "No incremental benefit of Liptruzet on cardiovascular morbidity and mortality over and above that demonstrated for atorvastatin has been established". Which begs the question, if Liptruzet is no better than generic atorvastatin, then why pay the inflated differential for a branded medication over a much less expensive generic?

By the way, this lack of benefit from ezetimibe should not come as a surprise because ongoing studies sponsored by its manufacturer, Merck, have failed to demonstrate any clinical outcome benefit when used in isolation or when taken in combination with Merck's simvastatin. So think twice in case your doctor offers you the latest in cholesterol lowering drugs.

Just How Fast Is Your Heart Beating?

Just under 2 months ago, I looked at a study attempting to predict cardiorespiratory fitness via non-exercise means. Of note, the authors linked body mass index and resting heart rate to CRF. But do we really care as much about CRF as we do our mortality? In fact, in a prospective cohort study published last month in Heart, the authors concluded that resting heart rate was an independent predictor of mortality, regardless of physical fitness, physical activity and the usual slew of cardiovascular risk factors.

The authors measured resting heart rate prior to testing physical fitness as measured by VO2max (oxygen consumption) in 2,798 Danish men who were then followed for 16 years. As demonstrated in a figure in the paper, there was an inverse correlation between physical fitness and RHR. In other words, those who were more fit as determined by a greater VO2max also had a lower RHR.

To my amazement, the 222 fittest men w/avg VO2max 38L/kg/min also had an average resting heart rate of just 48 beats per minute while the least fit 54 had an RHR greater than 90bpm. Typically, we declare anyone with heart rate less than 60bpm as being bradycardic, and very rarely, aside from exceptionally fit young athletes, do I see resting heart rates less than 56bpm.

Yet, after taking into account all the usual confounders, the authors noted that compared to those w/RHR less than 50bpm, mortality increased by 16% for every 10bpm increase in RHR. Those with what I previously considered an excellent RHR of just 51-60bpm had a 20% greater mortality compared to those w/RHR less than 50bpm. Those with a normal or average RHR of 71-80bpm had 33% greater mortality while those with RHR greater than 90bpm had more than twice the mortality of those w/RHR less than 50bpm. So just how fast is your heart beating now?

By the way, if you're worried and wondering about what you can do to lower your RHR and thus your mortality, aerobic exercise is the key, that is, after you've been cleared by your family physician to engage in exercise. So don't just sit there, do something!

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Thursday, May 2, 2013

Mediterranean Diet vs (Loss of) Memory

It never ceases to amaze me but I keep getting asked which is the best diet. Both patients & physicians want a definitive answer, even those who attended the recent American Academy of Family Physicians' Geriatric Medicine conference held in Santa Ana Pueblo, NM last week. Whether for fat loss, muscle gain, heart disease, diabetes, etc, we're all searching for that elusive best diet. Perhaps it's even scarier that so many different authors have stepped in to fill this void as we're inundated each day with the diet du jour. that claims to be the newest, greatest way to lose fat, gain muscle, prevent heart disease & treat diabetes. And of course, each of the authors claims to have discovered the key to unlocking the secrets of our poor health.

But if you think about it, typically when there are many clamoring for the attention of the same demographic, there usually isn't one best. Take cars, medications, music & movies, for example. Sure, we attempt to name a Car of the Year, and offer both a Grammy award & Oscar, but when it comes to medications, the best one is the one you can afford that will do what you want when administered in a manner & frequency which you can accept with tolerable side effects. Not so easy, right?

Likewise, when it comes to eating habits, we need to take into account cultural, ethnic & religious factors. But what separates diet & medications from cars, music & movies is the evidence available to support one's claim to best. And when it comes to diets, only the Mediterranean diet has continuous, consistent & compelling evidence to support its adoption. Most recently, a randomized controlled trial of the Mediterranean diet was shown to be better than placebo at preventing an initial cardiac event. Of course, we've always had plenty of observational data suggesting benefit from eating in a manner similar to the Mediterranean diet.

The best news is that earlier this week, a prospective, population-based, cohort study was published in Neurology in which the authors concluded that greater adherence to the Mediterranean diet was linked to lower risk of cognitive impairment. They followed 17,478 participants for an avg of 4yrs during which time cognitive status was assessed annually while food frequency was just assessed once at study onset.

And what of those other diets? While they can make any number of miraculous claims, none have peer-reviewed published outcome data to support their capitalistic attempts. So check out the Mediterranean diet and adopt your variation on a theme. No one stands to receive any (financial) gain, just you.

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Wednesday, May 1, 2013

You're Never Too Young to Get Healthy Part 2

A few years back, the American Academy of Pediatrics made the headlines by recommending that children & adolescents get their cholesterol checked. If you consider that heart & vascular disease is more likely to be lifelong issue rather than a short-term disease du jour, it makes sense to check periodically, especially when the kids are young. Along those lines, perhaps it shouldn't be too surprising that a prospective study published in last month's Pediatrics suggested that the Triglyceride:HDL ratio is a good way to assess arterial stiffness.

To be more specific, the authors analyzed 893 volunteers of whom avg age was barely 19yo, 2 in 5 were men, and just 1 in 2 were white. At that point, cardiovascular risk factors were linked to TG:HDL ratio in which higher ratios were tied to arterial stiffness in young children & adolescents. Just like the power of compounded interest, the sooner one starts improving one's health, the easier it'll be later on. In this situation, starting to aggressively manage high cholesterol as a youth may pay off dividends in terms of lower heart & vascular disease later on.

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Tuesday, April 30, 2013

ED & Heart Disease: It's All in the Plumbing Part 4

It's interesting that when it rains, it pours. Well, maybe. Or maybe it's more of the blind squirrel finding the occasional nut. In this particular case, while I was nosing around yesterday regarding the link between erectile dysfunction and heart disease, I stumbled upon yet another review published last August in the Mayo Clinic Proceedings. In fact, this review was a consensus statement of the third Princeton Consensus Conference held in November 2010 (notice how long it takes to get something published?).

Specifically, erectile dysfunction was linked to an increase risk for coronary heart disease, stroke & all-cause mortality. The group went so far as to recommend a cardiac evaluation for any man complaining of organic ED (a question raised at the AAFP's Geriatric Medicine conference last week).

More importantly, the authors pointed out a total of 9 studies linking low testosterone (or hypogonadism) to increase mortality. Granted this does not prove cause & effect, but it does compel us to set up a randomized controlled trial to address that possibility. And finally, the authors went so far as to suggest that all men w/ED should have their T level checked and replacement considered when appropriate. Wow! What a turn around!

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