March 2008

Medical-Intelligence

A Monthly Review of Recent Articles of Interest
by Marc D. Schwartz, MD

Table of Contents
Avoid In-Hospital Lung Clots
Survive an In-Hospital Cardiac Arrest
Medical Progress in In-Hospital Treatment
Oral Contraceptives Reduce Ovarian Cancer Risk
All That Glitters...
I’m Tired and I Wanna Go Home...from Tanzania
Quick Takes

Live Long and Prosper - Chapter One
Avoid In-Hospital Lung Clots
Blood clots of the lung are the most common preventable cause of in-hospital death. Medication and other measures to prevent it lower the risk by over half in medical patients and three quarters in general surgical patients. A recent study found that, among at-risk patients in the United States, only half of medical patients and three quarters of surgical patients received preventative medical and other treatment recommended by the American College of Chest Physicians. If you are hospitalized, check with your doctor to find out if you are “at risk for pulmonary embolism” and if you are getting the prophylactic treatment recommended

Live Long and Prosper - Chapter Two
Survive an In-Hospital Cardiac Arrest
In a study of outcomes of patients who had a pulseless cardiac arrest while in the hospital, it was found that all major outcomes, including survival and neurological damage, were less positive for those whose arrest occurred at night, between 11 PM and 7 AM. Some of the many known characteristics of nights in hospitals are lower staffing levels, less expertise of personnel on duty, less staff oversight, and less stringent patient monitoring practices. You can’t choose when to have a cardiac arrest, but it may be helpful to prepare a family member or friend to come to the hospital ASAP if you have do one at night. If your hospital allows it, they can camp out at your bedside and do their best to make sure you’re getting all the care you need. JAMA Feb 20, 2008 299:785

Medical Progress in In-Hospital Treatment
And while we’re discussing things in-hospital, let me introduce the Hospitalist, the new medical specialist who focuses only on treating in-patients. You may be disappointed to learn that substituting hospitalists for patients’ own doctors does not reduce the death rate or readmission rate. So far, studies suggest that its main benefit is reducing the length of stay.

Oral Contraceptives Reduce Ovarian Cancer Risk
Women who used oral contraceptives (OC’s) were found to have 25% less risk of ovarian cancer than those who did not take them. The longer a woman used them, the greater the protection, and benefits were observed up to 29 years after cessation. The editorialist of Lancet, where this study was published, argues that the decline in ovarian cancer resulting from the use of OC’s outweighs the small increase in risk for other cancers.

All That Glitters...
It appears that a quarter of patients taking aspirin do not get its anti-clotting benefit. In a group of 3,000 patients with established cardiovascular disease, adverse cardiovascular events occurred more often in aspirin resistant patients (40%) than in aspirin sensitive patients (15%). At the present time, it is not known which commercial laboratory test is best for determining aspirin resistance nor which anti-clotting drug to take instead of aspirin. (Herbals and vitamins are of little help.) You may want to ask your doctor to keep you up to date on progress with this issue. I’ll let you know if I hear of any news about this.

I’m Tired and I Wanna Go Home...from Tanzania
While many private health insurance plans reimburse for emergency medical expenses overseas, and some cover “medical evacuation” — moving sick or injured travelers to the nearest adequate hospital — almost no health insurance policies pay to bring travelers back home to the United States. And that can be the most expensive part of a health crisis abroad. An air ambulance from London to New York can cost $40,000; from Hong Kong, it can cost up to $100,000.

When shopping for overseas hospitalization insurance, it is important to understand the terminology. Typically, ‘evacuation’ means getting to the nearest medically appropriate hospital; ‘medical repatriation’ means getting you from there back home. Medical repatriation and can be bought for three months ($190 a person), six months ($290) or 12 months ($490).

The details of plans vary. Some cover additional expenses that might be incurred in a medical emergency overseas, like the cost of flying a relative to your bedside or the return home of your children or traveling companion. American Express Platinum members already have medical repatriation benefits. In June, AARP will begin offering the service to its members.

If you’re abroad, need hospitalization, haven’t planned ahead for a medical emergency, and don’t have the cash on hand to pay for it, there may still be a way home. The United States government may lend you the money. In 2006, the Overseas Citizens Services of the State Department issued 843 repatriation loans totaling a little over $1 million. (Once you get home, your passport is no longer valid until you pay the loan.) The office can also provide logistical support, translation services and medical referrals. To reach the office from overseas, call 202-501-4444, or contact the nearest embassy or consulate.

Quick Takes
People regularly taking anti-inflammatories like Motrin, Advil, etc. can cut their chances of having upper GI bleeding or ulcers in half by taking a proton-pump inhibitor like Prevacid or Prilosec (or generics).A web based calculator for predicting the risk of hip fracture is available at hipcalculator.fhcrc.org.

January 2008

An Explanation of the Current Controversy about Cholesterol Reducing Medications

By the early 1950's, it was becoming clear that the slabs of fatty material found in the arteries of adult’s hearts were not healthy. The material impeded the flow of blood, and enough of it could block an artery entirely and cause a heart attack. Cholesterol was a significant component of this material, called plaque, but it was not clear whether high blood levels of cholesterol contributed to its formation. Nonetheless, people began to look at blood cholesterol with suspicion.

In part to clarify the role of blood cholesterol in plaque formation, the NIH funded the Framingham Heart Study, which monitored thousands of people’s cholesterol levels and health status over time. In 1977, when research data from the study was analyzed, it came as a surprise that, in men and women over 50, total cholesterol was not a risk factor for coronary heart disease.

There was an interesting explanation for the surprise. Cholesterol is carried around in the bloodstream encased in a protein shell. Since cholesterol is a fat, the protein shell is called a lipo (= fat) protein. There are two kinds of lipoproteins - low density ones (LDL’s), that carry cholesterol to the body organs, and high density ones (HDL’s), that remove it from the body organs and bring it to the liver to be excreted or recycled.

The Framingham Study found that higher than average levels of LDL (carries cholesterol to organs) contributed to the risk of heart attack while higher than average levels of HDL (takes it from organs) lowered cardiac risk. (Mnemonic: it’s good to get a high score on high density lipoprotein.) The reason the total cholesterol levels were relatively meaningless was that high levels could be caused by high levels of cholesterol encased in LDL - which is bad- or by high levels of cholesterol encased in HDL - which is good. (The cholesterol in each of them was identical.)

A few years ago family of drugs called statins were found both to reduce LDL-cholesterol and reduce the frequency of heart attacks. The statins, including Lipitor and Zocor (see end of article for full list), quickly became the largest selling drug category in the world with annual sales of $40 billion. Naturally, companies making other drugs wanted to get into this market. Some of them developed other kinds of drugs (not statins) that reduced LDL, and the FDA approved them for sale.

But just because people who took a drug that lowered LDL got fewer heart attacks doesn’t mean necessarily that all drugs that lower LDL’s will reduce the frequency of heart attacks. Maybe the statins lower the heart attack rate by some other mechanism, like reducing inflammation, or by keeping artery walls healthy in some yet undetermined way, or by reducing some subset of particularly noxious LDL’s. Maybe other LDL lowering drugs won’t prevent heart attacks or might even have some negative effect that outweighs the positive effect on LDL’s.

Despite this uncertainty, the FDA’s has been approving and pharmaceutical companies have been selling new drugs that reduce LDL but have not been proven to reduce heart attacks or overall mortality. That this may be a mistake was highlighted by experience with one new drug that lowered LDL and raised HDL yet seemed to increase the incidence of heart attacks and strokes. Another drug made up of a statin plus a non-statin LDL-lowering drug was found to lower LDL much more than did either of them alone but may have caused more plaque. The drug companies selling the non-statin drugs have promised the FDA to do studies to determine whether their drugs actually lengthen people’s lives. But the FDA has historically put little pressure on the companies to keep their promises and actually carry out these studies, and most have not.

So, what seems certain: Statins lower LDL’s and also reduce the incidence of heart attacks and prolong life. (Currently available statins include Lipitor, Lescol, Lovastatin or Mevacor, Altoprev, Pravastatin or Pravachol, Rosuvastatin Calcium or Crestor, and Simvastatin or Zocor.)

All drugs that lower LDL’s may not prevent heart attacks. Specifically, non-statins and medications that combine a statin with a non-statin have not yet been shown to reduce the frequency of heart attacks or prolong life.

November 2007

Medical-Intelligence
A Monthly Review of

Recent Articles of Interest

Table of Contents
Promising Studies of Stroke and Cancer Treatment
Reducing the Risks Following Hip Fracture
The Final Word About Diagnosis and Treatment of Low Back Pain
Brief Notes

Two Promising Treatments Not Yet Ready for Clinical Use
Stroke
Stroke damage is caused by a lack of blood to a small part of the brain but is then made worse by inflammation of the damaged tissues surrounding the stroke. For some unknown reason, minocycline, an antibiotic, has anti-inflammatory effects. An Israeli team randomly gave 151 patients with a stroke caused by a clot either minocycline or placebo within 6 to 24 hours of their stroke then followed them for three months. The minocycline patients had clinically and statistically superior outcomes at 7 days, 30 days, and 90 days. More studies are underway.
Cancer
In some manner, stem cells from bone marrow are attracted to developing tumors. Once there, they produce a molecule that attaches to the tumor cell and greatly increases its metastatic potential. In test tube studies and in mice, drugs that block the molecule from attaching to breast cancer cells block the ability of the cells to metastasize. The next step is to see if these drugs work in humans. This study makes me wonder what kind of evolutionary process might have led to this complex collaboration between tumor and stem cell? It’s hard to think of a way that natural selection could have created it since it’s ultimately lethal to both the tumor and the stem cells.

Reducing the Risks Following a Hip Fracture
Patients who have hip fractures are substantially more likely to have subsequent hip and other fractures. In one study, over a two year period, 15% had a fracture, and 13% died of any cause. In this study, more than 2,000 patients received an IV dose of the osteoporosis drug, zoledronic acid (Reclast), within three months of surgery to repair their hip fractures. The study was halted in two years when it was noted that the treated group had 38% fewer new fractures of any kind and 27% fewer deaths. There were no major adverse effects of the drug.

The Last Word - for Now - About the Diagnosis and Treatment of Low Back Pain
The American College of Physicians and the American Pain Society recently published guidelines for the diagnosis and treatment of low back pain:
1. For patients with nonspecific back pain, carry out no routine imaging or other diagnostic tests.
2. Only for patients with severe or progressive neurological deficits or a possible serious underlying condition are imaging and other diagnostic tests suggested.
3. For evaluation of persistent pain or possible nerve root problems or possible spinal stenosis, imaging (preferably MRI) should be done only when the patient is being considered for surgery or steroid injections.
The not-so-subtle message of the guidelines seems to be: Stop Doing So Many Imaging Exams! Other recommendations are:
Give patients written information about prognosis and self care, encourage activity even in the presence of pain, and treat painful areas with superficial heat.
Use aspirin and anti-inflammatory medication (NSAIDs) as first line medications even though the evidence for their long term efficacy is weak.
For those who don’t improve with self-care alone, try careful spinal manipulation, intensive interdisciplinary rehabilitation, yoga, cognitive therapy, or progressive relaxation. (Why not chicken soup?) Skeletal muscle relaxants may work for acute pain, and tricyclic antidepressants may help with chronic pain.

Brief Notes
Students with allergic rhinitis (runny nose) taking an exam were 40% more likely to drop one grade point than those without rhinitis. Those taking a sedating anti-histamine were even more severely affected, with 70% more likely to drop a grade point. If at all possible, it would be best to arrange for testing of children with allergic rhinitis during symptom-free periods. Good luck.

A study of 8,000 patients suggests that weight loss surgery reduces long term mortality.

A "western" diet was defined as one with high intake of refined grains, red meat, high-fat dairy products, french fries, and desserts. Yum. A "prudent" diet was defined as one with high intake of fruits, vegetables, poultry, and fish. One thousand patients with Stage III (fairly advanced) colon cancer had their cancer and colon removed. Over the next two years, those eating a prudent diet had about 1/3 less chance of suffering recurrence or death than did those eating a Western diet.

A study has shown that the most cost-effective way to remove germs from raw fruit and vegetables is to spray them with a mixture of one part vinegar and three parts water then rinse them in water. In the course of their study, the researchers found this method was actually superior to rubbing the items on your shirt.

October 2007

Table of Contents
Cancer Risk from CT Scans?
Break a Leg - or Not
Psychotherapy Increases Survival in Some Breast Cancer Patients
Keep It Clean
Needed: A PhD Program in Patienthood
Brief Notes

Cancer Risk from CT Scans?
Does the radiation from a CT scan increase your risk of cancer? Ask most doctors, and they’ll say no (91% in one study). On the other hand, the keynote speaker at the annual meeting of the National Council on Radiation Protection and Measurement, the Chair of Diagnostic Radiology at Yale, says YESSS!! While 44% of radiologists thought a CT scan was equal to between one and ten chest X-rays, he reported that a single scan is actually equal to (put on your lead apron before you read this...) between 100 and 250 chest X-rays. Having numerous scans, which is not uncommon, puts one in the medium dose range of the atomic bomb (no joke). So, avoid CT scans when MRI or ultrasound offers comparable information, and avoid repetitive exams unless absolutely necessary.

Break a Leg - or Not
Calcium and Vitamin D supplements may reduce the risk of bone fracture in older people by as much as 25% if they are taken conscientiously. The medical journal, Lancet, found the effect to be strongest with doses of 1,200 mg of calcium and 800 units of vitamin D. It is not yet clear whether Vitamin D really makes a difference, but Lancet feels that if you are going to take it at all, take it at their suggested 800 unit dose, not the 400 units usually recommended.

Psychotherapy Increases Survival in Some Breast Cancer Patients
One hundred and twenty five women with metastatic or recurrent breast cancer were given supportive-expressive group psychotherapy or no psychotherapy for at least one year. Overall there was no difference in survival. But the subgroup of 25 women with estrogen receptor-negative cancer showed a highly significant improvement in survival with psychotherapy (30 months survival vs 9 months with no psychotherapy).

Keep It Clean
An important clue about the cause and treatment of urinary infection in children is the identification of colony forming bacteria in the child’s urine. It has been thought that collecting the urine starting a few seconds after the child starts urinating would reduce the bacterial contamination from the skin surrounding the penis or labia. To test this, mid-stream urine samples were collected from 350 children seen in an ER for a urinary tract infection. About half the children had the skin around the end of their penises or around their labia wiped with gauze and liquid soap. This group was more than three times more likely to provide a urine sample that accurately identified the cause of a urinary tract infection than was the group that had not been cleaned.

Needed: A PhD Program in Patienthood
A doctor tells a patient that he can choose one of three new treatments to prevent a heart attack. All three treatments were studied over a five year period. It was found that 13 patients had to be receive the first treatment to prevent one heart attack. The second treatment postponed a heart attack for 8 months for a quarter of the patients, but had no benefit for the rest. The third treatment postponed a heart attack for the average patient for 2 months. Which one should the patient choose?

Wait a minute, what did doctor say??? You’re not alone. A third to a half of 3,000 adults given these choices had trouble understanding and comparing the benefits of the treatments. It turns out that this was a hypothetical treatment study, and the three outcomes are equivalent - that is, there is no statistical difference between them. Still, 93% of subjects chose treatment number one, 82% chose number two, and only 69% chose number three. The difference was largely attributed to the fact that the more the subjects understood the statistics of the benefit, the more likely they were to accept the treatment.

Brief Notes
Estrogen and Heart DiseaseHealthy women between 50 and 59 who took estrogen alone were found to have no increase in coronary heart disease and significantly lower levels of coronary artery calcium than those who took placebo.

Vitamins Again
A study of over 8,000 women failed to show an overall benefit from taking Vitamin C, vitamin E, or beta carotene for prevention of heart problems. These are all anti-oxidant vitamins heavily advertised as conferring a cardiovascular benefit.

Bumper Pads
Over a recent twenty year period, there were 27 infant deaths related to the use of bumpers or pads in infant cribs or bassinets. Even the very low risk of strangulation or suffocation greatly outweighs the potential benefit of using the pads to reduce the incidence of minor bruises.

Asthma That Does Not Respond to Treatment
Occasionally difficulty breathing is misdiagnosed as asthma when it is actually due to the vocal cords pulling towards each other, rather than separating, during heavy breathing following exercise. If conventional treatment for asthma is not working, this condition should be considered.

September 2007

Table of Contents
Generic vs Brand Name I: The Taste Test
Generic vs Brand Name II: The Sleep Test
Generic vs Brand Name III: The FDA Test
Obesity Found To Be A Communicable Disorder - Really!!
Are Prescription Medicines for Treating Alzheimer's Worth It?
Intensive Care or Palliative Care. Sometimes It's Not an Easy Choice

Generic vs Brand Name I: The Taste Test
Sixty three children were fed five identical foods and drinks either in packaging having MacDonald's logos or similar packaging without the logos. For each pair of foods, the children were asked to point to the one that tasted better. Children significantly preferred four of the five foods and drinks that they thought were from MacDonald's. The taste preference was greatest in children whose homes had more TV sets.

Generic vs Brand Name II: The Sleep Test
Tryptophan is a sleep inducing food element. A study published in the American Journal of Nutrition showed that drinking milk, common lore notwithstanding, decreases the amount of tryptophan that gets into the brain. On the other hand, foods high in carbohydrate stimulate the release of insulin, which eases tryptophan's entry into the brain. If you really believe that milk works for you, it will (see MacDonald's test, above). Otherwise, try a Twinkie.

Generic vs Brand Name III: The FDA Test
A myth encouraged by the drug industry has it that generics are in some way not as good as brand name drugs. In fact, generic manufacturers must prove to the FDA that their drug delivers the same amount of active ingredient in the same time frame as does the brand name drug. The generic must have the same quality, strength (100%), purity and stability as the brand name drug. The manufacturing standards required of generics are identical to those required of brand name drugs, and FDA inspectors use the identical criteria while inspecting their facilities. In fact, 50% of generic drugs are produced by brand-name firms, which frequently make copies of their own or other brand name drugs and sell them as generics.

Obesity Found To Be A Communicable Disorder - Really!!
Researchers analyzed data from twelve thousand participants in the Framingham Health Study from 1971 to 2003. They found that a person's having friendship with a an individual who became obese during the study period was significantly associated with the person's developing obesity himself. (Read on before you decide the "himself" is sexist.). This correlation extended to a friend of a friend of a friend. An increase in weight correlated 100% for male to male friendships (!), only 38% for female to female friends (not statistically significant), and not at all for opposite-sex friendships. Overall, obesity in a friend was a stronger predictor than obesity in a sibling or a spouse. Obesity in a neighbor had no predictive value. If this study's findings can be replicated (which I doubt), maybe you'll need to change your friends, not your diet.

Are Prescription Medicines for Treating Alzheimer's Worth It?
The short answer is probably not. In numerous studies, patients taking these medications had a very small benefits on cognitive tests (just enough to get approved by the pharmaceutically funded FDA) but had no improvement in their ability to carry out day-to-day self-care tasks. - Neurology Jul 2007 69:459-69

Intensive Care or Palliative Care. Sometimes It's Not an Easy Choice
It is sometimes wrenching for doctors, patients and families to accept that a patient's illness is not curable and that active treatment is no longer needed. Thus the old nurse's joke: Why do they put nails in coffins? To make sure the doctors don't restart the chemotherapy. Palliative care is defined as active care of patients whose disease is not responsive to curative treatment. This can involve control of pain or other symptoms as well as psychological, social and spiritual support. The goal of palliative care is for patients and their families to achieve the best possible quality of life in the face of serious illness.

In a study of 130 patients in a medical intensive care unit (ICU), consultation with a palliative care specialist cut the average length of time seriously ill patients spent on the unit from two weeks to one week with no change in mortality. This does not mean patients should be prematurely hurried off the ICU. But sometimes a sensitive outside consultant can help doctors and families make more humane and reasonable decisions about treatment options for very seriously ill patients.

July 2007

Bottled Water and Dental Cavities. Plus Grandparent Advisory.
Over the Counter Fountain of Youth
Need to Take Antibiotics Before a Dental Office Visit? Maybe Not
Lumbar Disks Again
Treatment of Muscle Pain for Those Taking Cholesterol Lowering Medications
Dying for a Nicotine Fix
How Much Exercise Is Enough?
Kisses Lower Blood Pressure


Bottled Water and Dental Cavities. Plus Grandparent Advisory!
Fluoride in tap water is known to reduce dental cavities. So the recent increase in the use of bottled water, with some families never drinking any tap water, is troubling. In addition, filtering water removes variable amounts of fluoride. Worse yet, a third of US homes, including most that use well water, contain little or no fluoride. What to do? Fluoride supplements aren’t the answer because they can cause discoloration of the enamel. If the children are largely drinking bottled water, it may be useful to look in the baby-food aisle at the grocery store for "baby water" or "nursery water", which usually contains fluoride. Over-the-counter fluoride rinses and self-applied gels may also be used in children who are able to rinse and spit properly. Grandparent advisory: Carefully weigh the price of another fraught discussion with your grandchild’s parents against the risk of few extra cavities.


An Over the Counter Fountain of Youth
Aging, as some might know, leads to skin that is thin, lax, finely wrinkled, fragile, easily traumatized, and slow to heal. In a randomized, double-blind study, 36 subjects age 80 or older (mean age, 87) applied over-the-counter Vitamin A ointment (0.4% retinol) to one arm and a placebo ointment to the other about three times a week for 24 weeks. Treatments were skipped when the arm became irritated or excessively dry.

A 10-point scale that included wrinkling and roughness was used to evaluate changes from start to the end of treatment. Overall, the effects of aging improved by 1.25 points from Vitamin A and worsened by 0.06 on the control arm. Most subjects experienced some mild irritation on the retinol-treated arm, and five withdrew from the study for this reason. Twenty four weeks after retinol treatment ended , the royal carriage turned back into a pumpkin.

Need to Take Antibiotics Before a Dental Office Visit? Maybe Not
For the past ten years, it had been recommended that, to prevent endocarditis (infection of the heart valves), patients with virtually any kind of heart abnormality, including mitral valve prolapse, should take antibiotics before having a dental procedure. For a long time, many experts have questioned this strategy, noting that exposure to bacteria from tooth brushing or flossing year round gives thousands of times greater exposure than a few dental visits a year.

Recently, the American Heart Association reduced the list of cardiac conditions needing antibiotic prophylaxis before dental visits to four (artificial valves, infected valves, cardiac transplants, and certain congenital heart problems.) Most conditions, including mitral valve prolapse, were removed from the list. Also excluded were genito-urinary procedures unless there is a urine infection present and gastrointestinal procedures. The guidelines are posted on-line at dx.doi.org/10.1161/CIRCULATIONAHA.106.183095.

Lumbar Disks Again
Yet another study, this one of 683 patients, found that people with lumbar disk problems were no better a year after surgery than those who did not have an operation although the former had less pain in the first four to twelve weeks post-op.

Coenzyme Q10 for Muscle Pain in Those Taking Cholesterol Lowering Medication
The most commonly used medications to reduce high blood cholesterol, statins, often cause muscle related pain. They also interfere with the action of coenzyme Q10, which is necessary for producing energy in muscles. Hmm. Maybe giving extra Q10, despite its hokey name, could reduce the muscle pain. Thirty two patients taking statins and having muscle pain were treated with Q10 or a placebo. At 30 days, pain intensity decreased by 40% in those taking Q10 vs. no decrease for those taking placebo.

Dying for a Nicotine Fix
Most readers of Medical-Intelligence might have trouble thinking of an acquaintance who smokes. But they’re still out there. When they are hospitalized for a critical illess, would it hurt to give these poor folks a nicotine patch to ease their withdrawal symptoms? Well yes, it would. During their first 24 hours of admission, 90 smokers were given a nicotine patch and 90 not. Twenty percent of those given the patch died while in the hospital; only 7% of those not given the patch died. Sometimes you’re better off with a doctor who is not so tender hearted.

How Much Exercise Do You Have To Do to Increase Your Good Cholesterol
A recent study found that study participants could increase their HDL by over 2 mg/dL by exercising a minimum of two hours per week. Exercise sessions had to last at least 30 minutes but it didn’t matter how frequent or strenuous they were.

Kisses Lower Blood Pressure
At least five studies have found that people with high blood pressure who ate dark chocolate for varying lengths of time (up to 15 years) had lower blood pressure than those who ate white chocolate or drank tea.. In one study the "dose" of chocolate required to lower pressure was the equivalent of one and a half Hershey Kisses per day.

June 2007

In This Issue

Some Medical Tests Are Costly -- And Not Always Necessary
TV and Sex and Adolescents - Five Startling Hypotheses!!
Surviving the Psychological Stress of the ICU
Low Salt Diet Helps People Whose Blood Pressure is Not Really High

Before You Order, You May Want To Check the Price
When prescribing medication, four out of five doctors take your out-of-pocket cost into consideration when deciding whether to prescribe a generic rather than a brand name drug. Some doctors give greater consideration to this than do others. In one study, HMO doctors were most likely to consider cost (almost 90%) (They may have been thinking about the HMO’s cost as well as yours.) Over 80% of primary care doctors considered cost, while only 75% of specialists did.

In contrast, only 40% considered cost when deciding what diagnostic tests to order. This is important because some diagnostic tests can be expensive, may not be covered by insurance, and sometimes are not really necessary..

In my experience, for some work-ups, most doctors find certain tests to be almost mandatory while they view others as discretional. Some of the latter are ordered because it’s more convenient to order a batch of tests at one time then to order one then follow up later with others if necessary. Some are ordered out of medical curiosity, some for the doctor’s legal protection, and some because the patient suggested them,.
It’s not bad manners to ask a physician who’s ordering tests how much they may cost. Sometimes, he or she may actually know, and, in certain circumstances, the test might reasonably be deferred without any increased health risk.

TV Viewing and First Intercourse in Adolescents
Almost 5,000 students (53% female and 77% white) younger than 16 who had never had sexual intercourse were interviewed. A year later, 14% of those who viewed less than two hours of TV a day during the previous year had had intercourse. 18% of those who watched more than two hours a day had done so.

Was the increase was due to sexual excitement generated by TV programming? Was it a consequence of teenaged boys and girls spending hours of unsupervised time on a couch in front of a flickering box? Did sex on TV entice the kids to experiment themselves? Was extra TV-watching just a proxy for a lack of parental supervision? Were families that were more permissive about TV more permissive about sex? Why am I generating so many hypotheses? Whatever the explanation of the findings, the study provides another good reason for parents to oversee and limit adolescents’ TV viewing. - Ashby SL et al. Television viewing and risk of sexual initiation by young adolescents. Arch Pediatr Adolesc Med 2006 Apr; 160:375-80.

Leaving the Intensive Care Unit in Good (Psychological) Health
Over 200 patients who had been in a hospital intensive care unit (ICU) were interviewed a week or two after discharge about their experience. Three months later almost 10% were found to be suffering from Post-Traumatic Stress Disorder (PTDS) related to their stay in the ICU. Three factors were most clearly related to the PTSD: physical restraint without sedation, prolonged sedation, and delusional memories. If these kinds of events occur, it may be useful to call in a psychiatric consultant to develop and oversee interventions that can minimize stress and its after-effects.

A Low Sodium Diet May Save Your Life Even If Your Pressure Is Not (Really) High
Over 3,000 people with high normal blood pressure were assigned to a low sodium diet or a regular diet. Ten to fifteen years later, those in the low sodium group had 25% fewer heart problems, and 20% fewer of them died. The authors of the article recommend less sodium for everyone. Sigh. British Med J 2007 April 28;334:885

Feedback from Readers
Re: Recent notes in Medical-Intelligence on TIA's and strokes: to find a nearby hospital that is accredited to evaluate and treat stoke aggressively, check the site www.jointcommission.org/CertificationPrograms/Disease-SpecificCare/DSCOrgs Then check for "Your state" and “Primary Stroke Centers”. Also see the NY Times May 28, 2007 for more extensive reporting on the topic.

Disclaimer
Medical-Intelligence, including the email newsletter of that name and the blog Medical-Intelligence.blogspot.com, is designed for informational purposes only and should not be used in any other manner. It is not intended to substitute for informed medical advice, and the information it contains should not be used to diagnose or treat health problems or diseases. Because of possible errors in editing and interpretation, articles may be inaccurate or misleading. Furthermore rapid advances in medicine may cause information to become outdated or invalid.
Medical-Intelligence does not endorse any of the treatments, medications, articles, abstracts or products discussed on any of its pages or links. By reading Medical-Intelligence, you agree to hold harmless it and its owners and employees/volunteers from any and all liability arising directly or indirectly from your use of information contained in it.

May 2007 #2

Fish or have trouble cutting bait
Imagine you're pregnant. You think fish oil may be good for you, but you also know that fish oil contains mercury, which is bad for the baby. What to do? UK researchers studied data from almost 9,000 pregnant women and their offspring through age 8. (British and US seafood mercury levels are similar.) The children of mothers who ate more than 340 grams of seafood a week (a dinner portion of fish weighs about 230 grams) had significantly better neurodevelopmnetal outcomes including better fine-motor, communication, and social skills and higher verbal IQ. Pregnant women might want to spice any fish they add to their diets with a bit of skepticism as theses results are pretty amazing. And bear in mind that some types of fish have more oil then others (salmon, herring, flounder, pollock, sole), and others have more mercury (swordfish, tilefish, king mackerel.) . For details, see AmericanHeart.org/presenter.jhtml?identifier=3013797.

What's the Significance of a Mildly Elevated Fasting Plasma Glucose Level?
The Fasting Plasma Glucose (FPG) level is used in making the diagnosis of diabetes. An FPG below 100 is regarded as normal; one between 100 and 125 as impaired; while higher levels are in the diabetic range. Over 5,000 non-diabetics who had recently been found to have an impaired plasma glucose level were followed for an average of six years. Of those whose first abnormal level was between 100 and 109, about 1 % a year converted to diabetes. Of those whose first abnormal level was between 110 and 125, the conversion rate was five times greater. So, what can a person do if their level is mildly elevated? See below.

What To Do if Your Plasma Glucose Level is Mildly Elevated
British researchers compared three approaches to delaying the onset of diabetes in people with mildly impaired plasma glucose levels: lifestyle changes (weight loss and exercise), medications (metformin and acarbose) and a weight loss drug (Orlistat, which blocks intestinal absorption of fat). Orlistat was found to be the most helpful, followed by weight loss and exercise, then by medications. However, Orliststat's annoying side effects (greasy stools, occasional leakage of stool) have deterred many people from using
it. In this study, the effects lasted only as long as the patients followed their treatment regimen. In another study involving a more structured and intense exercise training program, the effects were much better and longer lasting.

Pay for Performance: Reward and Punish Health Care Providers Based on Their Results
It's the latest, it's the greatest. Pay for performance! It's so intuitively right that there's no need to test whether it works - just do it. In fact, while you were out taking a walk, more than half of all private HMO's have adopted such programs. Of course, there have been other intuitively right ideas: total mastectomy for breast cancer, hormone treatment for all menopausal women, to mention a few. The fact is, evidence linking pay for performance programs to better quality of care is surprisingly thin, and some evidence for its effectiveness is based solely on improvement in record keeping without much change in the underlying quality of care. In addition, most patients receive most of their care from multiple providers. Whatever. It is an idea whose time has come. Stand aside.

First Aid for Kidney Stones
As anyone who has passed a kidney stone can attest, it can be very painful. Ultra-sound and surgical interventions are risky and expensive. An analysis of studies on various medications treatments used to help patients pass stones, including steroids, NSAIDs, calcium channel blockers, and alpha-blockers., found them all to be helpful. This may reflect a common bias towards publishing only positive findings. In addition, the studies were small and varied in quality. Still, until more conclusive studies are done, people who can't wait may want to keep on hand the two prescription medications preferred by the journal editor, calcium channel blockers and alpha-blockers because they generally have the mildest side effects. There are about two dozen of these medications on the market including Verapamil, Norvasc, Procardia, Cardura and Flomax.

Is There a Problem Taking Aspirin for Your Heart and Advil or Motrin for Your Knee (or Headache)?
In short, yes, there is a problem. Abruptly discontinuing the aspirin you take each day or two can actually increase the cardiovascular risks that aspirin is intended to reduce. Taking an NSAID like Advil or Motein at the wrong time of day can block aspirin's action, which has the same effect as discontinuing it abruptly. Here's how it happens and what you can do about it.

Opening its spigot empties a rain-barrel in a few minutes, but it may take days for the water level to build up again. Similarly, it takes aspirin only a few hours to reduce a clotting factor in the blood but, once it's been reduced, it takes days for the body to build it up again. During those days, the lower level of clotting factor in your bloodstream makes it less likely that you will have a heart attack or stroke.

It's important to avoid having anything in your bloodstream during the first few hours after you've taken an aspirin that might block its action (that is, that might clog the spigot). Unfortunately, the non-steroidal inflammatory drugs (NSAIDs) like Motrin and Advil have this blocking effect, so it's best not to keep them out of your bloodstream until at least two hours after you've taken an aspirin. And since NSAIDs remain active in your bloodstream for about eight and a half hours after they're taken, you don't want to take a NSAID for eight or nine hours BEFORE taking an aspirin. All things considered, one good time to take aspirin might be at 7 AM (assuming you haven't taken an NSAID for eight and a half hours) and then not take an NSAID till after 9 AM. (This information recently appeared in the John Hopkins Medical Letter.)

May 2007

In This Edition

Choosing How To Treat a Blocked Coronary Artery
.....Why and How to Have a Medical Team on Your Side
A Cause for Anxiety
.....Why Cognitive-Behavioral Treatment Doesn't Help Some People's Anxiety
The Attack May Be Transient But The Risk May Not Be
.....Know Beforehand What To Do About a Possible TIA
Make the Baby’s First Car Ride a Safe One
.....Breathing Difficulties are Common in Preemies. Avoiding Them Is Easy
Good News! Grandpa Can’t Get His Blood Pressure Under Control
.....High Blood Pressure May Not Be A Risk in Those Over 80

Choosing How To Treat a Blocked Coronary Artery
Sometime soon, someone you know may be found to have coronary artery disease. Soon thereafter, sometimes very soon thereafter, they may have to decide whether to have a coronary artery by-pass graft (CABG, or cabbage as they say on the wards) or to have stent (a tiny tube inserted to hold open a coronary artery). A number of studies have compared the value of these two treatments, and while neither has been found to be clearly better than the other, two recent studies found CABG was less likely to lead to complications, was at least as likely to reduce mortality, and was more cost effective. (The stents studied were not the "drug eluting" type.) Still, many patients may do better with a stent. Until the indications are more definite, if you are choosing between the two, it is a good idea to ask your doctor to arrange a consultation for you with a cardiac surgeon who does stents, another who does CABGs, and a non-surgical cardiologist.

A Cause for Anxiety
Cognitive-behavioral therapy (CBT) helps with general anxiety in about half of cases. Why not the other half? Anxious people in committed relationships were treated with CBT. 62% got better. Those who those who experienced hostility from their partners failed to improve while those who experienced non-hostile criticism had significant reductions in anxiety.

The Attack May Be Transient But The Risk May Not Be
In a Transient Ischemic Attack (TIA), there is a temporary decrease in blood flow (ischemia) to part of the brain. It is usually caused by a spasm of a vessel or a partial blockage due to a tiny clot. The person experiencing a TIA suddenly feels faint, dizzy, off-balance, and may have a speech impediment, poor balance, numbness, and/or headache. Most often the effects disappear within a few days. Recent studies have led the National Stroke Association to upgrade its guidelines for assessing a TIA. The Association is now calling it a condition that requires emergency evaluation and treatment to avoid the possibility of permanent damage. It was found that found 10% of TIA’s were followed by a stroke within three months, with half of these occurred within two days. As I reported in the April issue of Medical-Intelligence, some very effective treatment works only within the first three hours after a stroke and is only available at emergency stoke centers. So know where your nearest "emergency stroke unit" is (use this phrase when asking about it) so you can get there quickly. When you arrive in the ER, immediately tell the admissions clerk that the person you are with may be having a stroke. Insist on being seen by a clinician ASAP. Minutes may count.

Make the Baby’s First Car Ride a Safe One
Almost one of five premature babies has breathing difficulties during the ride home from the hospital. (It does not seem to make a difference whether a car seat or car bed is used.) To avoid problems, be sure to place the baby’s head so the baby it can breathe freely; observe the baby carefully during the trip to make sure it is breathing well and has not vomited; and, if the trip is a long one, stop periodically to pick the baby up and change its position.

Good News! Grandpa Can’t Get His Blood Pressure Under Control
Four thousand hypertensive patients age 80 and older were studied. Most were taking anti-hypertensive medication and had an average blood pressure (148/72), normal for this age group. Surprisingly, during a five year period, a greater portion of those with blood pressure below 140/90 died than did those above 140/90. In fact, among these 80-plus year olds, how much higher than140/90 blood pressure was had no effect on mortality. More studies are underway to help understand these findings. But don’t any of you kids throw away your hypertension medication yet. Research continues to show clearly that uncontrolled high pressure is still bad for those younger than 80.

April 2007

Eliminating the Yuck Factor from Doing CPR
Most by-standers don't stop and give CPR if they come upon someone in the street who's just had a heart attack. They might be willing to do the chest compression part but find breathing into the mouth of a complete stranger off-putting. Would more people do CPR if they didn't have to go mouth-to-mouth? Investigators in Japan studied what happened to over 4,000 adults who had a cardiac arrest outside a hospital. About three quarters got no CPR at all. By-standers gave full CPR to 20% and chest compression only to 10%. Not surprisingly, the investigators found that CPR gave better neurological outcomes (less brain damage) than no CPR. But the surprising and good news was that doing just chest compression gave better results than doing full CPR. This is probably because interrupting chest compression to do mouth-to-mouth breathing reduced the amount of blood that was being pumped to the brain. So if you see someone who needs CPR, don't worry about the germs. If the victim is not breathing normally, coughing or moving, just place the heel of one hands over the center of the person's chest, between the nipples. Place your other hand on top of the first hand. Keeping your elbows straight, position your shoulders directly above your hands. Push down on the chest 1 1/2 to 2 inches at the rate of 100 pushes per minute.

Update on the Risks of Estrogen and Progesterone for Post-Menopausal Women
Two recent studies involving over 25,000 women found...
* Women over 50 taking estrogen only (not progesterone) had 5% fewer adverse health events (heart attack, stroke, breast cancer, etc) than those taking a placebo.
* Women in their 50's taking estrogen and progesterone combination (Prempro) had a slightly increased risk of stroke and breast cancer but no increased risk of heart attack. It is recommended that if women this age take hormone treatment that they monitor their blood pressure and have regular mammograms.
* Women in 60's and 70's taking Prempro had a definite increase in the risk of heart attack, stroke, and breast cancer. There must be strong reasons to justify taking it.
* Women who had hot flashes and night sweats were found to be at a higher risk of heart attack even without hormones, and this risk was increased by taking hormone therapy. (This data was reported in one study and will need to be confirmed.)
The term hormone therapy was used in this study to include both estrogen only treatment and also progesterone plus estrogen treatment. Since the former seems safe and the latter not, lumping them together makes one treatment seem more risky than it really is and the other more safe. It would be more informative to use the terms "estrogen treatment" and "progesterone treatment" in reporting the results of studies such as these..

Making Friends and Influencing People
Physicians who receive payments and other favors from pharmaceutical companies may have a conflict of interest when deciding whether to use treatments sold by those companies. Investigators tried to get information about such payments to physicians in the five states that have laws mandating public disclosure. In one of these states, only a quarter of pharmaceutical companies disclosed complete data. Access to data was restrictive and cumbersome. Companies labeled some payments "trade secret". In other cases, lawsuits were required to force disclosure. In one state, data showed that 7,000 physicians received a median payment of $1,000. Without access to better information, one can only guess what effects these payments have on prescribing habits. Console yourself with the knowledge that these payments probably have no greater effect on physicians' prescribing practices than pharmaceutical companies' contributions have on the votes of your congressional representatives or on the regulations of U.S. Food and Drug Administration, another willing recipient of their beneficence.

Time for the Annual Check-Up?
Periodic health exams (PHE) have the primary purpose of assessing the overall health and risk factors of an apparently healthy person by taking a history and doing a physical exam. PHE's may lead to early discovery of treatable diseases but they may also lead to tests and services that have no proven benefit. Reviewing over 30 studies, the authors found that PHE's were associated with more GYN exams, Pap smears, cholesterol testing, and blood tests of the stool. However, they had no consistent effect on clinical outcomes like disease detection, health status, cost, disability, or mortality. Their greatest benefit may be that they make some people worry less. On the downside, they're not generally covered by insurance or Medicare, so you'll probably have to pay for them yourself.

March 2007

It's Ten P.M. Do You Know Where Your Stroke Center Is?
It's late at night. An older person in your home suddenly has difficulty finding words or becomes weak or confused or has difficulty with balance or has sudden numbness on one side of the body or develops a severe headache. They may be suffering from the most common type of stroke, one caused by a clot (as opposed to a bleed). If you can quickly get the person to a hospital that has an emergency stroke unit that does rapid brain scanning, they may be given clot-busting treatment known as t-PA (tissue plasminogen activator). Given within three hours of a stroke, t-PA has been shown to significantly reduce disability. Since minutes count, it might be a good idea to call your local hospital in advance to find out the location of the stroke unit closest to you. Be sure that the unit does rapid brain scanning and uses t-PA as some units called stroke units consist only of a set of in-hospital beds for people recovering from a stroke.

Let's Hear it for the Mohels
A series of large studies have all shown that circumcision reduces the incidence of HIV by about 50%. Although the studies were carried out in the developing world, they have clear implications for the developed world as well. Those opposing circumcision on moral, esthetic, hedonistic, and/or heath grounds may want to reassess the benefit-risk balance of the procedure in view of these findings.

You Haven't You Taken Your Anti-oxidants Today? Good!!
It is generally agreed that oxidative stress may damage bodily functions. So why not take anti-oxidant supplements like beta-carotene, Vitamin A and vitamin E. Seems reasonable. (You can guess what's coming.) An analysis was carried out of the 47 best randomized studies done on more than 230,000 people, most of whom were healthy. It turns out that one reason not to take these supplements is that they cause a small but significant increase in mortality rate. Whoops. This was not true of those taking Vitamin C or selenium. But then again those supplements didn't seem provide any benefit either. On the positive side, the authors reassure us that it's still OK to eat fruits and vegetables that contain vitamins. That's a relief.

Quick. Where Is the Nearest Men's Room?
The most common treatments for Benign Enlargement of the Prostate (BPH) are surgery and medication. British investigators recently found that simple behavioral interventions had a prompt and lasting effect on BPH symptoms and reduced, deferred, or eliminated the need for these treatments. One hundred forty men (mean age 63) who were not taking BPH medicine were randomized to receive either "watchful waiting" or self-management training. Treatment failure was defined as marked rise in symptoms, acute urinary retention, or the use of medication or surgery. The failure rate for the usual care group at 3, 6 and 9 months was 42%, 61%, and 79%. That for the training group was only 10%, 19%, and 31%. Numerous strategies were taught including keeping daily fluid intake to 1500-2000 ml per day; double voiding; restricting fluids for 2 hours prior to retiring, during long journeys, or when out in public; avoiding caffeinated drinks; avoiding alcohol in the evening; avoiding large volume alcoholic drinks like beer; timing the use of BPH medications for when they're most needed; and others. Those suffering from BPH and their spouses can find details of the training program at www.bmj.com/cgi/data/bmj.39010.551319.AE/DC1/1

And Now, Introducing the New Diet Champion…
Four popular diets in the US are the Atkins (very low carb), the Zone (low carb), the Ornish (very high carb, very low fat), and the LEARN (planning what and when to eat). A study of the effects of these diets on 311 overweight, non-diabetic pre-menopausal women found that the diet that brought about the greatest weight loss in one year was…..the Atkins. It brought about an average weight loss of 10 pounds compared to 6 pounds with the Ornish, 5 pounds with the LEARN, and 3.5 pounds with the ZONE. Suprisingly. the Atkins, which allows you to eat a fair amount of meat, also brought about the greatest improvements in HDL cholesterol, triglyerides, and blood pressure, although these reductions were modest in size. The main finding of the study is the importance of eliminating from the diet, as much as possible, refined carbohydrates such as white bread, sugar, and soda. Several basic vitamins and minerals can be difficult to get in adequate amounts from a very-low-carbohydrate diet so you may need to take vitamin supplements.

February 2007 (2)

Grandchild Got Colic?
Eighty three breast fed infants with colic (more than 3 hours of crying more than 3 days a week, ugh) received either lactobacillus reuteri (5 drops, once daily, 30 minutes after eating) or the anti-gas medication simethacone. Over 95% of mothers whose infant took lactobacillus reported a reduction in crying to less than 3 hours vs only 7% of those whose infants took simethacone. On day 28, average crying time among those taking lactobacillus as 51 minutes vs 145 minutes for those taking simethacone. The editors of Journal Watch wonder if these results are too good to be true and suggest that controlled confirmatory studies be carried out before this treatment is adopted. But after two and a half hours of watching the baby cry, you may not want to wait.

You May be Sharing More than You Want To
The woman has a vaginal trichomonas infection, her male partner is asymptomatic. She gets treated, gets better, then comes down with it again...and again. Until recently it was difficult to determine if her partner was reinfecting her. New nucleic acid amplifications tests (PRC) enable much better identification of trichomonas in men. A study was carried out of over 250 men whose partner had trichomonas. While the vast majority of men were asymptomatic, over 70% tested positive for trichomonas using PRC compared to only 10% testing positive using traditional tests like culture and microscopic exam of urine and semen. The study justifies the practice of routinely treating the partner of infected women. Condoms can also be used to prevent transmission.

How Much Has Retroviral Therapy Increased the Life Span of Patients with HIV?
A study in Denmark of 400 HIV-infected persons and 400,000 controls found that median survival for a 25 year old HIV infected person treated with retrovirals was 34 years compared with 51 years for controls. Although disheartening for HIV patients and their families, it was an improvement over the 20 years of survival rate before retrovirals were introduced.

Do Anti-depressants Reduce Coronary Mortality in Depressed People with Coronary Artery Disease?
Among patients with Coronary Artery Disease (CAD), depression strongly predicts CAD mortality. Might SSRI's help reduce this mortality? Almost 300 depressed patients (average age 58) with a history of heart attack or angioplasty were treated with either interpersonal therapy (IPT) or no IPT and were given either the SSRI citalopram or placebo. Depression improved in 36% of those taking citalopram and 23% of those taking placebo though those taking citalopram experienced more tiredness and sexual dysfunction than those taking placebo. About 30% of those treated with IPT or no IPT improved. There was no improvement in cardiac mortality or morbidity.

How Long Are Your Telomeres?
Each time your cells divide, their telomeres (ends) get shorter. (Who would have thought it?) Thus the length of your telomeres are a measure of your biological age. Might short telomeres indicate an increased risk of age-associated disease like coronary artery disease? The short answer is yes. The risk of coronary events is nearly 50% higher in people with short telomeres than in those with long telomeres. But, if you are a short telomere person, do not despair. Among short telomere individuals taking statins, there was no significant association with coronary disease. So maybe, if your cholesterol is low but your telomeres are short, you should take statins. At any rate, this study lends credence to animal studies th at have found that slowing cellular aging might lower the risk of atherosclerosis. As you can imagine, there is a lot of research being done on how to age cells more slowly. As soon as you find out how to do it, let me know.

Will Daily Multivitamins Make You Healthier?
The rate of infection was studied in over 750 elderly people who were given either a daily multivitamin or placebo for 18 months. No difference. Multivitamins have never been shown to help any group of well people.