Aetna Latest Healthy Living News Latest Healthy Living News from Aetna en Aetna Latest Healthy Living News Latest Healthy Living News from Aetna TYPO3 - get.content.right Fri, 21 Nov 2014 00:00:00 -0500 No Solution Found for People Skipping Pills Only half of people who take medicines on their own actually take them as prescribed, studies...                    What Is the Doctor's Reaction? One day last year I welled up into tears in my office. I was seeing one of my favorite patients, a lively older Greek man whom I had doctored for years. My patient had terrible psoriasis. His blood pressure was always high. And his diabetes was in terrible control. Over and over, I had sent him home with good medicines to manage these problems, but I rarely made headway. Why? He did not take his medicines. So why did I cry? I cried because he was a changed man that day. He had been changed by a stroke. He had just been discharged from the hospital. He could not speak, and he could not move his right side. His blood pressure had caught up with him. My patient had to live in a nursing home after that. Nurses gave him his medicines. The effect was remarkable. His rash cleared up. His diabetes was in perfect control on much lower doses of medicine than I had ever believed he would need. His blood pressure was easily reduced to our goal level. He and I both know that his stroke could have been avoided. It turns out that only half of all patients who are responsible for taking their own medicines actually take them as prescribed. Within months of a heart attack, one-third of patients start failing to take their blood pressure and cholesterol medicines. When written prescriptions are tracked, 14% of them are never filled at a pharmacy. Another 13% are filled but never taken. A research group called the Cochrane Collaboration just reviewed 182 studies that tried different ways to help people reliably take their medicines. The report's conclusion was that overall we really don't know how to solve this problem. Cost is not always the issue. More than one out of four people fail to take cholesterol medicines consistently beyond their first two years of treatment. This occurs even when the price is fully covered by insurance. So what is it that gets in our way when we fail to take our medicines? My own patients give me a variety of reasons when I notice that they have missed pills. Usually they say they are forgetful about it. I think they say that because they don't want to hurt my feelings. I think the real reason people don't take pills is that they don't believe in them. It is hard to believe in pills that are used to treat chronic illness. What Changes Can I Make Now? Be honest with yourself. If you don't take prescribed medicines, what is the real reason? Here are two that might be at play:
  • You don't feel sick enough to need pills. Chronic illness, such as high blood pressure, can raise your risk of heart disease or other health problems. Even knowing these statistics, you may secretly believe you were born lucky. When you underestimate your risks or how serious your illness is, this is called denial.
  • You don't have enough information to weight benefits and risks. In order to take a medicine reliably, you need to believe in its value.
Denial and a lack of information are bad reasons to not take your medicine. I think it may help to take fewer medicines. But make a commitment to the ones you don't want to miss:
  • Pare down your medicines to a shorter list. Schedule a visit and tell your doctor that you want to get rid of medicines you don't need.
  • Keep a clear list at home. It is ideal if you can keep a list on a computer. Then you can adjust the list and print a new copy after each doctor's visit.
  • Know what each of your medicines does for you. Ask your doctor the purpose of each medicine. Write it down. Is each one worth taking? You should be able to write "worth it!" next to every medicine you keep on your list.
  • Get information about side effects. If you have a side effect from a medicine, you need to consider both the drug's benefit to you and its problems and risks.
  • Plan a system to help you remember. A weekly pillbox can be very helpful. Take your pills at a routine time, with meals or when you brush your teeth. If picking up your prescriptions at a pharmacy is a challenging errand, change to a mail-order pharmacy for your most important medicines.
What Can I Expect Looking to the Future? With a little motivation, this should be a simple problem to solve. What if a drug company began to make pills that combine medicines people want to take with medicines that people tend to miss?
For example, my patients do a great job taking pain medicine, antidepressants, Viagra, birth control pills and even anti-wrinkle medicine. But they miss their pills for blood pressure, cholesterol and diabetes. Maybe we need a few brands out there like "Vico-statin" or "Diabeto-ED" that make the important medicines more "sexy."]]>
Fri, 21 Nov 2014 00:00:00 -0500
At Best, Type 1 Diabetes Doubles Death Risk No matter how well they control their blood sugar, people with type 1 diabetes have at least twice...                      What Is the Doctor's Reaction? People with diabetes have a lot to keep track of. They have to follow a "diabetic diet," watch their weight and take all of the recommended medicines. There are appointments with various doctors to keep. And then there's the worry that related health problems will develop anyway, such as kidney, eye or nerve disease. The first order of business is getting the blood sugar down. People accomplish this with diet, exercise, medicines or all of these. But good blood sugar control is a primary goal of any diabetes treatment plan. And yet, several recent studies have shown that keeping the blood sugar normal or nearly normal may not be helpful as previously thought. A new study is the latest to show the limits of this "tight control." The New England Journal of Medicine published the study. Researchers looked at blood sugar levels and death rates among nearly 34,000 people with type 1 diabetes. This form of diabetes develops when the body's immune system attacks the insulin-producing cells in the pancreas. This leads to a lack of insulin. Without insulin, the body can't use glucose (sugar) normally. Blood sugar levels rise. Other health problems commonly develop.  Compared to people without diabetes, those with diabetes:
  • Were more than 3 times as likely to die during the 8 years of the study.
  • Were nearly 5 times as likely to die from a heart or circulation problem.
  • Were 9 to 10 times as likely to die during the study if their blood sugar control was poor. This was defined as an average blood sugar of 230 milligrams per deciliter (mg/dl) or higher. A normal blood sugar is 80 to 120 mg/dl.
  • Were more than twice as likely to die during the study even if their average blood sugar levels were less than 149 mg/dl. Death rates for this group were not any better than those for diabetics with "fair control" (150 to 174 mg/dl).
To me, one of the most striking findings of this study was the increased risk of death despite good glucose control. The other was that people with the best blood sugar control did not live any longer than those with fair control.   Even so, these findings don't mean that good control of blood sugar isn't important. Problems such as vision loss or kidney failure are more likely with higher blood sugar levels. These and other health problems linked with diabetes can impair quality of life. It's also possible that the researchers would have seen lower death rates if they had analyzed even lower average blood sugar levels or studied the impact of tight control for more than 8 years. What Changes Can I Make Now? Learn what you can do to prevent diabetes. Type 1 disease, which was studied in this latest research, is not currently preventable. But type 1 accounts for only 5% of all diabetes. The rest is type 2 diabetes. Type 2 diabetes is closely linked with excess weight. Obesity causes cells in the body to resist the action of insulin. But avoiding excess weight can prevent most cases of type 2 diabetes. People with slightly high blood sugar levels ("pre-diabetes") may be able to avoid developing diabetes by taking a medicine called metformin. Despite the findings of this new research, people with diabetes should test their blood sugar often. This allows them and their doctors to adjust medicines and avoid high blood sugar. The most helpful measure is called glycated hemoglobin (hemoglobin A1C). The test shows an average blood sugar over the last 2 to 3 months. The ideal level is not entirely clear. If it's too low, nausea, fainting and seizures may occur. But very high levels are hazardous also. Ask your doctor what blood sugar range you should aim for. Your doctor probably will also suggest these steps to help prevent more health problems:
  • Eat a well-balanced diet. It should be low in sweets, cholesterol and total calories but rich in whole grains, fruits and vegetables.
  • Get regular exercise.
  • Lose excess weight.
  • Don't smoke.
  • Take medicines to control blood sugar (including pills or injections of insulin).
  • Take medicines to lower cholesterol.
  • Keep your blood pressure normal. Losing excess weight and cutting back on salt can help control blood pressure. Your doctor can prescribe medicines if necessary.
  • Take a daily aspirin.
  • Take an ACE inhibitor medicine (such as enalapril) to lower blood pressure and help protect the kidneys.
  • Make regular visits to an eye doctor and foot specialist.
What Can I Expect Looking to the Future? Research has led to major improvements in the treatment of diabetes. Yet people with this disease still have unacceptably high rates of further health problems and early death. You can expect to hear about more research that will address these important issues.  We know a lot about how to prevent type 2 diabetes. I hope that new cases of this disease will fall over time. Given the current epidemic of obesity, however, it's unlikely that will happen anytime soon.]]>
Thu, 20 Nov 2014 00:00:00 -0500
How Long to Take 2 Anti-Clotting Drugs? People who take anti-clotting drugs longer after a heart procedure may reduce their risk of heart...                      What Is the Doctor's Reaction? After a blocked heart artery is opened with a balloon, standard therapy is aspirin and a second drug that also helps prevent blood clots. How long a person should take both drugs remains an open question. Two studies presented at this weekend's American Heart Association Scientific Sessions looked at this issue. Every year, millions of people around the world have one or more blocked heart arteries opened with a balloon. The procedure is called coronary angioplasty. To keep the artery open, the doctor puts in a tube called a stent. The stent is made out of wire mesh. The first stents contained only bare metal. In some people, the bare metal triggers blood clots inside the stent. This is rare. But when it happens, it can cause a  deadly heart attack. After the stent is placed, the metal will get covered naturally by the same kind of cells that line normal blood vessels. They are called endothelial cells. This process takes three to four months. In the meantime, people take aspirin and a second drug for three to six months to prevent clots. It's known as dual anti-platelet therapy. Anti-platelet drugs help prevent platelets in blood from clumping together to form clots. After dual therapy, the patient takes aspirin alone, with no fixed end point. But there is another problem with bare metal stents. About 10% of patients receiving a bare metal stent have too much growth of endothelial cells into the stent. This can continue for one to two years, or even longer. The excess growth can cause another blockage inside the bare metal stent. Because of this problem, a new type of stent was developed. These stents are coated with a drug that helps prevent endothelial cells from forming over the metal. They are called drug-eluting stents. With the newer stents, there is much less chance of extra buildup of the endothelial cells. But this also means that the metal does not get completely covered in new cells. So the risk of a sudden blood clot lasts longer. And this requires longer dual anti-platelet therapy. Experts recommend dual therapy for a least one year. But even after a year, stopping the second drug increases the risk of a sudden clot in the stent. Stopping also increases the risk of a heart attack and stroke, unrelated to the site of the original angioplasty. The major risk of dual anti-platelet therapy is bleeding. Moderate or severe bleeding is higher if you take two drugs than if you take aspirin alone. What Changes Can I Make Now? If you have had coronary angioplasty and stenting, you need to stay on aspirin, with no set end point. This will be true no matter how long you took dual anti-platelet therapy. If you are allergic to aspirin, a different clot-preventing drug will be prescribed instead. Regarding taking both aspirin and a second drug, these new reports support what previous studies have suggested. The choice of how long you should continue dual anti-platelet therapy after angioplasty will be based on your own situation. If you have a high risk of bleeding, doctors will try to shorten the number of months you take two drugs. People at high risk of bleeding include those who have severe liver or kidney disease or a history of bleeding from the stomach or intestine. Even then, for a bare metal stent, the goal would still be dual therapy for three months. For a drug-eluting stent, the goal would be at least six months. Given the potential benefits of preventing heart attacks and strokes, you and your doctor might decide to continue dual anti-platelet therapy with no end point. The risk of moderate to severe bleeding is higher than if you took aspirin alone. But the bleeding episodes during the 30-month study reported in the New England Journal of Medicine study were rarely fatal. What Can I Expect Looking to the Future? The most commonly anti-platelet drug prescribed along with aspirin is clopidogrel (Plavix). There are two newer drugs that can be used instead of clopidogrel. They are prasugrel (Effient) and ticagrelor (Brilinta). Studies are underway to determine if dual anti-platelet therapy with either of these drugs is better and/or safer than clopidogrel.]]> Mon, 17 Nov 2014 00:00:00 -0500 Japanese Study: No Heart Protection from Aspirin In a study from Japan, taking daily low-dose aspirin did not reduce the risk of early death for...                    What Is the Doctor's Reaction? One of the most common questions that healthy men and women over 50 ask me is "Should I start taking an aspirin?" Patients know about the good effects of aspirin in preventing heart disease and stroke. We learned about this effect from well-done and well-publicized studies dating back to the early 1990s.   Patients want to hear: "Yes, you should take an aspirin," or "No, you shouldn't." Doctors want to be able to give a clear, straightforward answer. In truth, the answer has become less clear over time. To answer the question, doctors have to really understand the person in front of them. Is the patient male or female?  What is his or her specific risk, based on race, gender and medical history?      This study is an important addition to the data. It was presented at the American Heart Association Scientific Sessions in Chicago. Conducted in Japan, the study enrolled almost 15,000 people. Their ages ranged from  60 to 85. All of them had health factors that increased their risk of heart disease. These included high blood pressure, high cholesterol or diabetes. People  took their regular medicines. Half of them also took a daily low-dose aspirin.  This study was stopped early. The group of experts keeping track of the data felt that aspirin was unlikely to be of any major benefit to those who were taking it. Everyone had fewer heart attacks and strokes than expected. Yet, in this study, taking aspirin did not seem to have a role in decreasing that risk. The data suggested some benefit in decreasing the risk of heart attacks and transient ischemic attack (sometimes called "mini-stroke"), but the study was not designed to measure this specifically.  In this entirely Japanese population, the risk of all kinds of bleeding did increase. This study is particularly interesting to us for several reasons:
  • We know that Asian people are more likely to have hemorrhagic (bleeding) strokes than other populations. But so far there has been little research on aspirin use among Asians.
  • This study also highlights the importance of gathering robust data in non-white populations.
  • The study shows that, over time, it has become much harder to do research on the role of aspirin in preventing heart attack and stroke. This is likely because other medicines, such as statins for cholesterol, have so much benefit as well. 
  • Many people in the study stopped their aspirin. Others in the non-aspirin group started to take an aspirin during the study. An editorial explains that this was unlikely to affect overall results. But it does point out the challenges of doing long-term research in the 21st century, when people are mobile and have so much access to medical information.
In summary, this study will help doctors to help our patients decide whether or not an aspirin a day is a good idea. It doesn't allow for an easy yes or no. But it does contribute to a more nuanced view that will help make the safest, best decision for each person. What Changes Can I Make Now? If you are over 50 and considering taking an aspirin a day, discuss it with your doctor. He or she will likely review your:
  • Risk of heart disease in the next 10 years
  • Risk of stroke
  • Risk of bleeding
Together, you can decide whether the benefits of a daily, low-dose aspirin outweigh the risks. Whether your doctor suggests aspirin or not, it's important to change factors that may increase your risk of heart and blood vessel disease. Here's what you can do to protect your heart and brain:
  • Maintain a healthy weight.  Keeping your body mass index between 20 and 25 is hard in our society, but so valuable for your overall health.
  • Quit smoking.
  • Eat a heart-healthy, portion-controlled diet.
  • Exercise several times a week.
If you have high blood pressure, diabetes or high cholesterol, work with your doctor to bring your blood pressure, blood sugar and cholesterol as close to the normal range as you safely can. Take your medicines daily as prescribed. If you want to know more about your own heart disease risk, one way to look at it is using this risk calculator.  Many other calculators can be found as well. Remember, this study was for people who have not had a heart attack or stroke. If you have a history of heart disease already, then the benefits and risks of aspirin are quite different. What Can I Expect Looking to the Future? I think this study beautifully highlights the role of personalized medicine. Doctors need to think with patients about their risk of heart disease and stroke and make medical decisions based on the person sitting in front of us. Fortunately, three studies are in the works to help us make better sense of the risks and benefits of aspirin in many different settings.  Stay tuned!]]>
Mon, 17 Nov 2014 00:00:00 -0500
U.S. Investigates Generic Drug Price Hikes U.S. officials are investigating recent large price increases in several generic drugs. A...                    What Is the Doctor's Reaction? The prices of certain generic drugs have skyrocketed. But what's just as amazing is how variable the prices are on any given day. Yesterday, November 13, I checked on the retail prices of two of the drugs mentioned in the article -- doxycycline and digoxin. Doxycycline is a commonly used antibiotic. It has been prescribed since 1967. It is the best oral drug for Lyme disease. It is also used to treat many infections that resist other antibiotics. A shortage of the materials needed to make doxycycline interrupted the steady flow of the drug. Generic drug makers that could keep making it hiked the average retail price from just over 6 cents per pill to more than $3 per pill. Digoxin is a heart drug used for people with atrial fibrillation or heart failure. For many decades, it was one of the few drugs to treat these conditions. Today, doctors have a lot more options and prescribe it less often. Only three companies now make this very old drug. With less competition, they have been able to raise the average retail price tenfold in less than two years. I called two different well-known national pharmacies to get pricing. I also looked up pricing for a so-called discount pharmacy online. The following are retail prices. That means this is how much anyone would need to pay if he or she did not have any type of drug coverage or insurance. At large national chain pharmacy No. 1, prices per pill were very close to those cited in the article:
  • Doxycycline: $3.19 per pill
  • Digoxin: $1.14 per pill
Online discount pharmacy:
  • Doxycycline: $3.33 per pill
  • Digoxin: $1.93 per pill
Large national chain pharmacy No. 2 gave me two prices. One was a full retail price.  The other was a discounted price. Full retail at pharmacy No. 2:
  • Doxycycline -- $6.20 per pill
  • Digoxin -- $2.43 per pill
But here is the great news. Pharmacy No. 2 offers a discounted price to all customers -- no special coupon, no strings attached:
  • Doxycycline -- $1.00 per pill
  • Digoxin -- $0.33 (yes, 33 cents) per pill
What Changes Can I Make Now? Even if you have excellent health coverage, you are likely paying a larger fraction of your health care bills these days. For most of us, out-of-pocket expenses are up. These include copays for drugs and visits to the doctor's office and emergency room. So you probably have a direct personal interest in bringing costs down. You can save money on drugs. As your doctor starts to write a prescription, here are some things to ask that can lower how much you pay:
  • Are there lifestyle changes I can make to either avoid taking this drug or at least start at a lower dose?
  • Can I get a generic version? Only a handful of generic drugs have become extremely expensive. You can almost always save by buying a generic drug rather than a brand name.
  • If no generic is available, is there another option that costs less and works as well as what you are prescribing? Is this brand the one preferred by my insurance company? (A non-preferred brand may cost more.)
  • Can I split this pill in half? For many drugs, the higher dose doesn't cost much more than the lower dose. By splitting a higher-dose version in half, you can save a lot of money.
After you have a prescription, you can save in other ways, too.
  • Shop around, especially if you don't have a drug plan and need to pay retail prices. I called only a couple of the well-known pharmacy names and discovered potentially huge savings.
  • Consider buying a three-month supply of drugs that you know you will take for a long time. Examples include drugs for high blood pressure, diabetes and high cholesterol. You may save on insurance copays if you do this and order by mail.
  • Talk with your pharmacist about ways to save money. Given the thousands of drugs on the market today, your doctor may not know about all the options.
What Can I Expect Looking to the Future? Right now no federal agency has any authority to mandate changes in pricing policies of drug companies as long as they allow free competition. The U.S. Senate and the U.S. Department of Justice have launched investigations into drug pricing. But big decreases in drug prices will not happen quickly unless more companies gear up manufacturing of these high-cost generics.]]>
Fri, 14 Nov 2014 13:34:00 -0500
B12, Folic Acid Pills May Not Help Memory B-vitamin pills may not help preserve memory in certain high-risk older adults, a study finds. The...                    What Is the Doctor's Reaction? Wouldn't it be great if improving your memory were as easy as taking a vitamin? Unfortunately, there's no proof that it's true. In fact, studies in recent years have questioned the idea that routine vitamin use is worthwhile for most people. A new study examines the impact of taking two B vitamins -- folic acid and vitamin B12 -- on memory. The study looked at older adults who were considered at high risk for memory loss. They had high homocysteine levels in the blood. This has been linked with damage to blood vessels and a tendency to form blood clots. Past studies have suggested that high homocysteine levels may increase the risk of heart attack, stroke and memory loss.  Folic acid and other B-vitamins can lower homocysteine levels. So it makes sense that reducing levels by taking vitamins might lead to better brain function. But that's not what the study found.  Researchers tested the thinking skills and memory of more than 2,900 older adults with high homocysteine levels. Each day, half of them took folic acid and B12. The other half took a placebo. After 2 years, they were tested again. Here's what the new tests found:
  • Homocysteine levels fell, as expected, in those receiving folic acid and B12 pills, compared with those who took the placebo.
  • Overall scores for memory and thinking skills were similar for both groups.
  • The results of the Mini-Mental Status test, a screening test for dementia, showed a slight benefit to those taking B vitamins. But it was so small that it may have been due to chance.
Many recent studies have failed to find a benefit for people taking vitamin pills. That's why the U.S. Preventative Services Task Force offers no advice about the use of a single or multiple vitamin to prevent heart disease or cancer. For beta-carotene and vitamin E, this influential group actually recommends against routine use.  Despite the results of this study and others, questions remain: 
  • Do some healthy people benefit from taking vitamins?
  • Can taking vitamins prevent or slow any diseases?
  • Which vitamins are most important to take? What's the ideal dose, and how long should you take them?
What Changes Can I Make Now? Patients often ask me if they should take a vitamin.  Many already take a multivitamin "as insurance," to get all the nutrients they need. Although there are exceptions, I tell most of my patients that taking a vitamin is unnecessary. But I also tell them that when it comes to getting enough vitamins, maintaining a healthy diet is important. Some vitamins seem to be more effective when they are part of your diet, not taken as pills. For example, the vitamins C, E and beta-carotene (which turns into vitamin A) in food act as antioxidants. They help to prevent tissue damage linked with aging, pollution and sunlight. But people taking vitamin C, E and A pills don't seem to benefit. So, if you are healthy and eat a balanced diet, vitamin pills may not provide you with any real benefit. But some people should take vitamins. They include:
  • People with vitamin deficiencies. Someone with low blood levels of vitamin D or B12 should take pills to raise levels to normal.
  • Pregnant women. Folic acid taken during pregnancy can reduce the risk of serious birth defects.
  • People who do not absorb vitamins normally. Examples include people who have had part of the colon removed, past obesity surgery or inflammatory bowel disease (such as Crohn's disease).
  • People taking certain medicines. For example, someone taking methotrexate for rheumatoid arthritis is usually advised to take folic acid to reduce the risk of side effects.
  • Those with higher than normal vitamin needs. For instance, hemolysis causes red blood cells to be rapidly destroyed. Someone with this condition needs extra folic acid to help the body replace the lost red blood cells.
Ask your doctor if you should be taking a vitamin.  But don't be surprised if he or she says it's not necessary. What Can I Expect Looking to the Future? You can expect researchers to keep exploring the connections among vitamin pills, health and disease.  We may need longer follow-up to know whether folic acid and vitamin B12 have any benefit for people with high homocysteine levels. This latest research lasted 2 years. But it's possible that we might see a benefit if tests of memory and thinking skills were repeated after 5 years or more of treatment. Some vitamin pills may help prevent disease. If a disease tends to get worse, other vitamins may slow that process.  And too much of certain vitamins (such as vitamin A) can be harmful. In the future, researchers will keep trying to figure out who should take a particular vitamin, how much is best and how long to take it.]]>
Thu, 13 Nov 2014 14:09:00 -0500
Study: End-of-Life Care Costs Less in Hospice Cancer patients in hospice care are much less likely than other patients to receive aggressive...                    What Is the Doctor's Reaction? This study highlights the potential cost savings when patients with advanced cancer, and a poor prognosis, move into hospice care. Aside from cost savings, aggressive care may not be consistent with patient and family desires once they are fully aware of the poor prognosis. And hospice care at the right time improves quality of life for a person's remaining days. What is the right time? For a doctor, deciding the right time to suggest hospice care is a complex and difficult task. The right time to have a hospice discussion is different for every patient. Mr. S. is my most recent example. I first met Mr. S. in the hospital 5 weeks ago. He had advanced bladder cancer and a bowel obstruction. He had lost 40 pounds. His prognosis was dismal. However, his own outlook was unrealistically optimistic, and he wanted aggressive care. In the first couple of days I took care of him, he was already on a path to two surgeries. One surgery would open the bowel obstruction. The other surgery aimed to take out as much bladder cancer as possible. He was not at all ready for a hospice discussion at that time. Instead, he did have the surgery to relieve the bowel obstruction. His recovery was complicated. He stayed in the hospital for three weeks. His bladder cancer continued to grow.  It caused a blockage of urine from both his kidneys. Tubes were placed through the skin into both kidneys to prevent kidney failure. As these problems occurred and Mr. S.'s health grew worse, the cancer surgeon still talked about possible future surgery to remove his bladder cancer. That's what Mr. S. wanted to hear. Mr. S. finally made it home. But he was back in the hospital within three days. He still held a hopeful outlook. He held on to the belief that he could gain weight and get stronger to have bladder cancer surgery. I knew that was never going to happen. With the help of the palliative care team and great support from his wife, now was the time to talk about hospice. He went home with hospice and died peacefully at his wife's side nine days later. The costs of his surgery, the procedures to keep his kidneys working and the many days of hospital care were huge. Fortunately, he had health insurance to cover almost all of the costs. This is the challenge for all of us -- doctors, patients and families. We want to be cost conscious, but we also need to respect the desires of people as they confront death. What Changes Can I Make Now? As doctors go through medical school and advanced training, our desire to cure becomes deeply ingrained. We don't want to acknowledge that no treatment will prevent the eventual outcome of death. We therefore tend to wait too long to let the patient and family know the real prognosis. Knowing this can help you and your loved ones who have advanced cancer or some other condition that is clearly going to end life soon. It helps your doctor when you ask, "Is continuing with aggressive therapy going to improve my quality of life?" Aggressive therapy may not only impair quality of life, but shorten life as well. For example, a study of patients with lung cancer and a poor prognosis showed that the ones who moved into hospice care lived longer than those who continued to receive aggressive cancer therapy. Even before considering hospice, talk with your doctor about palliative care. This does not mean that other care stops. Palliative care can begin at any time during a serious illness. The goal is to help improve quality of life. It does not take the place of other active care, such as chemotherapy. And it does not matter how long the person is expected to live. Palliative care accomplishes this by:
  • Focusing on emotional as well as physical needs
  • Making the relief of pain and suffering a top priority
  • Providing active support to loved ones and caregivers
What Can I Expect Looking to the Future? For the vast majority of those who are terminally ill, we wait too long to begin the transition to hospice care. Mr. S. is just one example when the process takes longer and costs more than it should. Doctors must and can do better at presenting the real prognosis with empathy and a focus on quality of life.]]>
Wed, 12 Nov 2014 19:50:00 -0500
Medicare to Cover Lung Cancer Screening Older longtime smokers and ex-smokers on Medicare soon may be able to get screening tests for lung...                    What Is the Doctor's Reaction? Private health insurers are required to cover the cost of screening tests recommended by the U.S. Preventive Services Task Force. It's part of the Affordable Care Act. The task force recommends screening tests based on a thorough evaluation of the evidence. This is done by a panel of independent experts. Medicare is not required to follow the task force's advice. But it almost always does. Last year, the task force recommended screening for lung cancer with low-dose CT scans. Medicare officials were wary of the costs of screening. They also wanted more time to review the evidence. So far, Medicare has not paid for lung cancer screening. This is about to change. Surgery offers the best chance to cure lung cancer. A cure is more likely when the cancer is small and confined to one spot. But lung cancer is often detected too late or has spread too quickly to be cured by surgery. For decades, researchers have been looking for the best way to find small lung cancers. They had no success until studies showed that low-dose CT scans could be an effective screening tool. The task force says that low-dose CT scans of the chest should be offered each year to heavy current smokers and ex-smokers who:
  • Are between the ages of 55 and 80
  • Have smoked for at least 30 pack-years (packs per day multiplied by years of smoking)
  • Quit smoking less than 15 years ago
  • Are healthy enough to have lung cancer surgery
Medicare coverage will be similar. But Medicare will cover screening from 55 to 74 years old. This is the age range of the largest study that showed the effectiveness of lung cancer screening with low-dose CT scans. The scans must be done at centers with radiologists experienced in performing and reading them. Medicare also will require that the centers submit information on scan results, follow-up and outcomes for all Medicare patients. What Changes Can I Make Now? Finding lung cancer early is clearly a benefit of annual CT screening. But such a strategy has downsides as well. The scans will undoubtedly find many lung "spots" that are not cancer and would never cause any harm. Up to 20% of the scans will show areas of concern. More tests will be required to find out if lung cancer is really present. That may mean more radiation from repeat CT scans. Some people will need more invasive testing, such as a lung biopsy or bronchoscopy, to determine if the spot is a cancer. Bronchoscopy is a procedure in which a tube is threaded down into the airway. Biopsy and bronchoscopy are generally safe procedures. But rare problems can occur, such as bleeding or a punctured lung. Ultimately, only about 5% of suspicious spots will turn out to be lung cancer. Having a CT scan every year raises some important concerns:
  • How much harm from radiation might yearly scans cause?
  • Will the costs actually be greater than currently predicted?
  • Will screening cause fewer people to quit smoking because they believe they won't die from lung cancer?
CT scans can't prevent lung cancer. Nor can they detect early cell changes that can turn into cancer. At best, they can detect lung tumors early enough that the odds of a cure by surgery are good -- but not guaranteed. The best way to prevent lung cancer is to never smoke or to quit. One of the lessons we've learned is that it is never too late to quit. If you quit at age 60, you stand to tack on about three years to your life expectancy. Quit at 50, and you earn six extra years. Quit at 30, and a whole decade is deposited into your life expectancy account. What Can I Expect Looking to the Future? The Centers for Medicare and Medicaid Services came under a lot of public pressure to cover yearly lung cancer screening. But their reluctance is understandable given the importance of trying to lower health care costs. Everyone on Medicare, including people who don't smoke, will pay an extra $3 per year to add this service. Yet only current and ex-smokers will receive this benefit. Shouldn't cigarette taxes be increased instead and applied directly to pay for lung cancer screening?]]>
Tue, 11 Nov 2014 14:10:00 -0500
Study: Obesity Surgery as Safe as Other Types Gastric bypass causes no more short-term problems than other common types of surgery, a new study...                    What Is the Doctor's Reaction? Yesterday I was working with a resident, a medical school graduate who is receiving on-the-job training. Together, we saw a patient who was in her 30s. She was obese. She was in the office because she was preparing to have obesity surgery. The young woman's body mass index (a calculation that considers weight and height) was 42. That is very high. But the resident had doubts. "I don't understand why she would choose to do surgery," the resident said to me. "She doesn't have diabetes. In fact she doesn't have any complications from her obesity. Wouldn't the risks of this surgery be larger than its benefits?" His question was a really good one. In fact, I wasn't sure how to answer. If obesity is your only health problem, is obesity surgery more likely to help you or hurt you in the long run? Earlier this week, a report in journal Lancet Diabetes & Endocrinology looked at the effects of weight-loss surgery. It showed that this surgery reduced the risk of being diagnosed with diabetes by 80%. That is substantial. Another study in the news this week also makes obesity surgery look pretty good. The journal Diabetes, Obesity and Metabolism published the study online. This study was not about obese people who were otherwise completely healthy. Instead, it looked at obese people who had diabetes. The study found that the rate of complications (medical problems) from weight-loss surgery was low. Researchers looked at more than 16,500 patients. They found that in the first 30 days after gastric bypass surgery, the complication rate was 3.4%. This is not bad for a major surgery. The 30-day death rate for gastric bypass patients was 0.3% -- again, not a very bad statistic. But this study did not last long enough to check for long-term complications. It is pretty common for gastric bypass to cause medical problems that occur months or years later. Long-term or delayed problems can include:
  • Vitamin deficiencies and other nutrition problems
  • "Dumping syndrome," when food moves rapidly out of the stomach, causing episodes of low blood pressure and very low blood sugar
  • Gallstones
  • Kidney stones
  • Belly pain
  • Ulcers in the intestine
In my primary care practice, I have seen every single one of these problems after obesity surgery. They are no picnic. What Changes Can I Make Now? For the right person, gastric bypass surgery can be a successful way to improve health. The benefits of weight-loss surgery are remarkable. It can restore blood sugar to normal for most people with diabetes. It also improves blood pressure and cholesterol levels. A typical patient loses 20% to 28% of the pre-surgery weight within 5 to 6 years. Survival is better, too, unless a serious complication occurs at the time of surgery or soon after. Most experts think it is reasonable to pursue weight-loss surgery if you have made careful efforts to lose weight through diet and exercise, and if your weight is in this range:
  • A body mass index (BMI) of at least 40, with no obesity-related illnesses
  • A BMI of 35 to 39.9, with at least one of these obesity-related illnesses:
    • Diabetes
    • Sleep apnea
    • High blood pressure
    • Cholesterol problems
    • Hypoventilation (being unable to completely fill your lungs)
    • Fatty liver disease
    • Headaches from the condition pseudotumor cerebri
    • Acid reflux
    • Asthma
    • Venous insufficiency with leg swelling
    • Severe problems with bladder or bowel control (incontinence)
    • Severe arthritis
I think I agree with these guides, as long as your obesity-associated illness is fairly severe and difficult to manage without control of your obesity. If you do pursue weight-loss surgery, make sure you carefully consider possible long-term complications. What Can I Expect Looking to the Future? Surgery for obesity does not enable obese people to eat without strict attention to calories. (You might say it is no "cakewalk.") Losing weight and maintaining the loss after obesity surgery require a long-term effort to eat less and stay physically active. Still, surgery is a valuable tool for managing weight loss in people with a very high BMI.]]>
Fri, 07 Nov 2014 14:35:00 -0500
Some NSAIDs May Increase Stroke Deaths People who take certain pain relievers may be more likely to die soon after a stroke, a new study...                    What Is the Doctor's Reaction? Nonsteroidal anti-inflammatory drugs (NSAIDs) are often prescribed to treat arthritis, headaches and other aches and pains. They are among the most commonly prescribed of all medicines. Examples include ibuprofen and naproxen, which are also sold over the counter. As an arthritis doctor, I recognize how helpful these medicines can be. But the side effects are also important to consider. They include:
  • Problems in the stomach and intestines, such as pain and ulcers
  • Kidney damage
  • Bruising or bleeding
Stomach problems are common -- and potentially serious. For this reason, a new type of NSAID was developed in the late 1990s. These drugs are known as  selective Cox-2 inhibitors. They suppress the action of an enzyme called Cox-2 that is linked with inflammation and pain. Older NSAIDs also suppress Cox-1, an enzyme with a role in protecting the stomach lining. So Cox-2 inhibitors suppress inflammation with less impact on the stomach than older NSAIDs. Cox-2 inhibitors include celecoxib (Celebrex), rofecoxib (Vioxx) and valdecoxib (Bextra). Soon after their approval, however, Cox-2 inhibitors were linked with an increased risk of stroke and heart attack. Rofecoxib and valdecoxib were withdrawn from the market. Celecoxib is still commonly prescribed. So are some older NSAIDs that suppress Cox-2 somewhat more than Cox-1. These include  etodolac (Lodine) and diclofenac (Voltaren). A new study examines whether taking a Cox-2 inhibitor or other NSAID increases the risk of death among people who have a stroke. Researchers looked at data for more than 100,000 people who were admitted to the hospital for stroke during the last decade. Researchers used data from the national health care system in Denmark. This allowed them to collect complete survival information on a large number of patients. They also knew what prescription medicines people took. Here's what the researchers learned:
  • About 10.4% of those taking a Cox-2 inhibitor died within 30 days of having a stroke. Among those not taking NSAIDs, 8.7% died. This represents a 19% increased likelihood of death for those taking a Cox-2 inhibitor.
  • The increased risk of death was primarily among those who recently started to take an older Cox-2 inhibitor, such as etodolac or diclofenac. Among stroke survivors taking these drugs, the increased risk of death was 42%.
  • The link between stroke and Cox-2 inhibitor use was limited to ischemic stroke. This is the most common type of stroke. It is caused by a blockage of blood flow that damages a portion of the brain.
  • No increased risk of death after stroke was seen among those taking "nonselective" NSAIDs, such as naproxen or ibuprofen. They suppress both Cox-1 and Cox-2 enzymes.
These provide more evidence that Cox-2 inhibitors may not only contribute to an increased risk of heart attack or stroke but also to an increased risk of death when these events occur. This information, combined with previous studies, should lead some people to avoid these drugs when there are suitable alternatives. What Changes Can I Make Now? If you have factors that increase your risk of heart attack or stroke, it may be best to avoid taking Cox-2 inhibitors. Risk factors include:
  • Advanced age
  • A family history of heart and blood vessel disease (for example, a parent, sibling or child who had a heart attack before age 55)
  • High blood pressure (hypertension)
  • High cholesterol
  • Diabetes
  • Smoking
  • An abnormal heart rhythm called atrial fibrillation
Do what you can to reduce or eliminate the risk factors you can change. For example, giving up smoking can reduce your risk of heart disease or even change your risk to normal.     If you are taking an NSAID, talk to your doctor. This is especially important if you have one or more of the risk factors listed above. NSAIDs that inhibit Cox-2 more than Cox-1 include:
  • Celecoxib
  • Meloxicam (Mobic)
  • Etodolac (Lodine)
  • Diclofenac (Voltaren)
  • Nabumetone (Relafen)
If you are getting significant benefit from an NSAID, continuing it may be appropriate. This is likely to be the case if you have no risk factors for heart and blood vessel disease. But it's important to take another look at whether the NSAID is providing a benefit and if it's causing problems. Let your doctor know of any side effects you have. People taking NSAIDs regularly also should have blood tests from time to time. These tests should look for signs of anemia or impaired kidney function. What Can I Expect Looking to the Future? I think you will continue to see drug makers develop medicines that retain the benefit of an older drug while reducing side effects. That was the reason Cox-2 drugs were developed. Unfortunately, unexpected -- and serious -- side effects were discovered. Perhaps the next generation of NSAIDs will have a better balance of benefit and risk.]]>
Thu, 06 Nov 2014 00:00:00 -0500
Guidelines Push Liquids to Prevent Stones The best thing people who have had a kidney stone can do to prevent more is to drink lots of...                      What Is the Doctor's Reaction? About 10% of Americans will have a kidney stone at some point in their lives. A stone that gets caught moving down from the kidney to the bladder usually causes symptoms. The most common is pain, often severe. Other symptoms can include bloody urine, nausea and vomiting. Having that first kidney stone puts you at risk for a second one. With no treatment, about 40% of people will have symptoms from a second stone. The American College of Physicians just released new guidelines on prevention of second stones. The group did not find enough evidence to support any particular preventive strategy other than drinking lots of fluids. However, the researchers only used clinical trials to create the guidelines. In a clinical trial, similar patients are randomly assigned to follow one treatment or another. Researchers did not include observational studies. This type of study compares what happens when people follow different practices based on their own choices or what their doctors prescribe. The results of observational studies do suggest that other strategies may help prevent second kidney stones. For example, they show that certain dietary changes and some drugs reduce future risk of stones. Also, when doctors do blood and urine tests and/or analyze the stone, the treatments they prescribe lead to a lower chance of another attack. The researchers doing the review had a limited number of clinical trials to include. In most of them, there was only weak evidence for or against anything other than drinking more liquids. So the guidelines have to state that there is not enough evidence to make conclusions other than increased fluid intake. This does NOT mean that other strategies won't help. Kidney stones form when:
  • Urine contains so much of certain chemicals that they turn into solids
  • Urine doesn't contain enough natural stone-preventing substances to stop solids from forming
  • Urine contains more than the usual amount of a substance that is known to act as a trigger for stone formation
About 80% of kidney stones contain calcium. Most often, oxalate is the chemical that hooks up with calcium. The resulting stones are made of calcium oxalate. But some kidney stones are made of other chemicals. This review had another important limitation. Most people in the clinical trials had stones that contained calcium. What Changes Can I Make Now? Based on observational studies and what most experts recommend, I still plan to advise my patients to follow these steps to help prevent even a first kidney stone. Drink enough water. Drinking water dilutes the chemicals in urine that lead to stones. If you have had a kidney stone, strive to drink enough liquids to pass 1½ to 2 quarts of urine a day. It may help to include some citrus drinks, such as lemonade and orange juice. The citrate in these beverages helps to stop stones from forming. Eat calcium-rich foods. The most common problem for people with calcium oxalate stones is that they absorb too much oxalate from their intestines. The kidneys must get rid of this oxalate. So the concentration of oxalate goes up in the urine. The calcium in foods and drinks binds to the oxalate inside the gut. Less calcium goes out in the urine. This reduces the chance that stones will form. Decrease sodium (salt) in your diet. A high-sodium diet can trigger kidney stones because it increases the amount of calcium in your urine. Federal guidelines suggest limiting total daily sodium intake to 2,300 milligrams (mg). If you have had a kidney stone, try to reduce daily sodium to 1,500 mg. Limit animal protein. Eating too much animal protein increases the amount of uric acid in the urine. This can cause uric acid stones. It also can act as a trigger to form stones that contain calcium. A high-protein diet also reduces levels of citrate. This is the chemical in urine that helps prevent stones from forming. Limit stone-forming foods if you have a history of kidney stones. This applies only to people known to have passed a calcium oxalate or calcium phosphate stone. Beets, chocolate, spinach, rhubarb, tea and most nuts are rich in oxalate. Colas are rich in phosphate. Both of these can bind to calcium in the urine to form stones. These are all healthy suggestions. Even if there is no proof of stone prevention, you still are helping yourself stay healthy in other ways. What Can I Expect Looking to the Future? I don't think the new guidelines will change current practice and advice for patients with one or more kidney stones.]]>
Wed, 05 Nov 2014 13:35:00 -0500
Study: More Bleeding with Pradaxa than Warfarin People who take dabigatran (Pradaxa) to prevent stroke may have more bleeding problems than those...                    What Is the Doctor's Reaction? People with atrial fibrillation have an abnormal heart rhythm. This leads to an increased risk of stroke. For decades, the best prevention meant taking the so-called blood thinner warfarin (Coumadin). But taking warfarin means you need regular blood tests to make sure your dose is correct. You also need to pay attention to how much you eat of foods rich in vitamin K. In 2010, the Food and Drug Administration (FDA) approved the first alternative to warfarin. The FDA put the blood thinner dabigatran (Pradaxa) on a fast track for approval based on a well-designed clinical trial. The study compared warfarin vs. dabigatran to prevent strokes in people with atrial fibrillation. None of the patients had abnormal heart valves. In this one study, people taking dabigatran had a lower risk of stroke than those who took warfarin. The risk of major bleeding was similar. The risk of bleeding into or around the brain was higher with warfarin. But patients on warfarin had a lower risk of other types of bleeding, such as bleeding from the stomach or intestines. After the approval, doctors began to report more cases of major bleeding from dabigatran than expected. The FDA required that more studies be done on the safety of dabigatran once patients in the real world started taking it. Some studies suggested a higher bleeding risk with dabigatran than reported in the first study. Other studies did not find higher risk. In this latest study, researchers used Medicare data to compare dabigatran to warfarin. They found that overall bleeding risk from dabigatran was indeed higher than first reported. It also was substantially higher than the risk from warfarin. The bleeding risk was especially high in African-Americans and people with impaired kidney function. However, dabigatran caused fewer episodes of bleeding in and around the brain compared with warfarin. What Changes Can I Make Now? Two other blood thinners have been approved to prevent strokes in people who have atrial fibrillation and no heart valve problems. They are apixaban (Eliquis) and rivaroxaban (Xarelto). Post-approval studies on these drugs are still underway.      The three new drugs cost much more than warfarin. But they don't require regular blood tests to adjust the dose. Potential long-term side effects remain unknown. So how do you and your doctor decide which drug is right for you if you have atrial fibrillation? There is no right answer. Here are the questions I ask:
  • Is cost an issue? If yes, warfarin will be the likely choice.
  • Are you sure you will take the medicine as prescribed? This is important for all of the drugs. But warfarin stays in the body longer, so you have a longer protection time. Stopping the other drugs even for a couple of days increases your stroke risk.
  • Do you have easy access to get regular blood tests? If the answer is no, then one of the newer drugs might be better for you.
  • Do you take other medicines twice a day? Apixaban and dabigatran have to be taken twice a day. Warfarin and rivaroxaban are taken once a day. Taking medicine twice a day means you are more likely to miss doses, especially if you are not taking other drugs on the same schedule.
I prefer to use warfarin first in people with atrial fibrillation. I do this primarily because of my conservative approach to new drugs. I also have many years of experience with warfarin. Should the patient have trouble keeping blood test results in the proper range, I then consider switching to one of the newer drugs. I might start with a newer blood thinner in a person with a higher than average risk of bleeding into or around the brain. Examples include someone with:
  • Uncontrolled high blood pressure
  • Any personal history of bleeding inside the head
  • A family history of bleeding inside the head
  • Alcohol abuse
What Can I Expect Looking to the Future? You can expect to read about more studies comparing the newer drugs to each other and to warfarin. The results will help doctors guide the choice of blood thinner for each of their patients with atrial fibrillation. ]]>
Tue, 04 Nov 2014 14:08:00 -0500
Brain Differences Found in Chronic Fatigue A small new study suggests there are clear differences between the brains of people with and...                    What Is the Doctor's Reaction? Chronic fatigue syndrome is a complex illness. It is difficult to diagnose because it's defined by symptoms. Some tests help support the diagnosis. But someone with this syndrome can have completely normal blood tests, X-rays and scans. This study suggests a possible new way to help diagnose chronic fatigue syndrome. Profound fatigue is the main symptom. But the official diagnosis also requires having at least four of these symptoms for at least six months:
  • Impaired memory or concentration
  • Headaches that are different from any you have had before
  • Sleep that doesn't make you feel refreshed
  • Exhaustion after physical exertion
  • Swollen, tender lymph nodes
  • Muscle pain
  • Joint pain
  • Sore throat
Most other causes of persistent fatigue come on gradually. Chronic fatigue syndrome tends to appear suddenly. Often it begins with a flu-like illness. Experts strongly suspect the main problem relates to something abnormal in the brain and other parts of the nervous system. However, MRIs and other types of brain imaging have shown inconsistent results. In this new study, researchers used more sophisticated MRI techniques. They did find a consistent difference between the brains of people with chronic fatigue and the brains of healthy people. People with the worst chronic fatigue symptoms also showed the most dramatic changes on an MRI. The authors recognized that this was a small sample. Only 15 people with chronic fatigue were compared with 14 healthy people. The specific cause of chronic fatigue syndrome is still a mystery. Researchers around the world are studying the disease. Most likely a viral infection is the cause. But that still remains to be proven. What Changes Can I Make Now? Fatigue is a very common symptom. When it doesn't go away, people often worry they have chronic fatigue syndrome. However, it accounts for just 3% of all cases of long-lasting fatigue. Twice as many women as men have it. It's important to rule out the many other causes of fatigue. They include:
  • Not enough quality sleep
  • Stress
  • Depression
  • An underactive thyroid (hypothyroidism)
  • Anemia
And that's just a sampling of a very long list of possible causes of long-lasting fatigue. There is no specific treatment for chronic fatigue syndrome. The most common advice is to set priorities and engage in a structured exercise program. Set priorities. Make a list of the things that you want to have more energy to do. Weed out as many nonessential things as you can. The goal is to conserve your energy for the most important activities in your life. Try to reduce the stress and fatigue that can come from having too much on your schedule. Get exercise. An exercise program can be very effective in relieving symptoms. At first, choose exercise that is light enough that it doesn't cause exhaustion. Gradually try to increase your time of exercise and level of exertion. Don't rush it. Pushing too quickly defeats the purpose. Some people with chronic fatigue syndrome are helped by cognitive behavioral therapy. This is a type of talk therapy. It can help identify and change negative thoughts and behaviors, especially related to exercise. Also, sometimes a low dose of a tricyclic antidepressant, such as amitriptyline, at night can be useful. What Can I Expect Looking to the Future? Surely these results will encourage more research to verify the findings in larger studies. It would be terrific to have a test to help doctors make a more secure diagnosis of chronic fatigue syndrome.]]>
Fri, 31 Oct 2014 14:02:00 -0400
High-Fat Diets May Help Adults with Epilepsy A high-fat, low-carbohydrate diet may help adults as well as children to control epileptic...                    What Is the Doctor's Reaction? For people with epilepsy, reducing the number of seizures -- or halting them -- is an important goal of treatment. A treatment to do just that could be as close as the kitchen. Epilepsy is a common condition. It causes sudden -- and often unpredictable -- changes in the brain's electrical activity. These changes produce seizures (also called convulsions). Someone having a seizure may lose consciousness and move the arms or legs uncontrollably for a short time. If only one part of the brain is affected, symptoms may be more subtle. They may include a brief episode of twitching, blinking or "spacing out." Treating the cause of epilepsy can be effective. For example, surgery to remove a brain tumor or an abnormal blood vessel in the brain can cure the condition. But often no cause can be found. Most people with epilepsy rely on medicines to prevent seizures.  But, according to a review of previous studies, a high-fat diet might help. The journal Neurology published the review. Researchers analyzed past research of high-fat, low-carbohydrate diets such as the Atkins diet. The studies included a total of more than 130 people with epilepsy. Here's what they found:
  • About one-third of people adopting this type of diet had at least a 50% reduction in seizures.
  • About 9% of those on the most stringent diet (called the "ketogenic diet") had a more than 90% reduction in seizures.
  • The drop in seizures occurred within days or weeks of the diet change. It lasted as long as people stayed on the diet.
  • Side effects of the diet were minor. Weight loss was one of the most common.
But the news from this study was not all good.
  • The benefit of the high-fat diet did not last when people went back to their usual diets.
  •  It was difficult to follow the high-fat diet over the long term. Up to half of those in the study stopped the high-fat diet before the study was over.
Changing the diet in this way is already common for children with seizure disorders who do not respond well to medicines. But this review is among the best evidence so far that it can also work well for adults. This could allow better seizure control for the millions of adults with epilepsy. It also could improve our understanding of how to control seizures. Further research could lead to new medicines or other diets that are even more effective or easier to stick with. What Changes Can I Make Now? If you are one of the 50 million people worldwide with epilepsy, it's important to know your options. Talk to your doctors about:
  • Treatment of the cause -- As described above, if there is a known cause of your seizures, removing the cause can stop them.
  • Medicines -- There are more anti-seizure medicines now than ever before. Taking one (or more than one) can be highly effective. Regular doctor visits and blood tests are usually recommended. It's important to let your doctors know of any side effects.
  • Surgery -- It may be reasonable to consider surgery when:
    • A cause of the seizures (such as scar tissue or a tumor) can be identified and removed.
    • Medicines don't help, especially if surgery can be done safely on the part of the brain where the seizures begin.
Unfortunately, even with these options, many people continue to have seizures. Some have unacceptable side effects from the medicines they take. And, even when they are well-tolerated, medicines don't work well for more than one-third of people with epilepsy. So we badly need more and better treatments. Could changing your diet help? This new study suggests that it could. However, before going on a high-fat, low-carb diet as a way to treat seizures, talk to your doctor. Some may find this diet appealing. For example, it includes foods such as bacon, heavy cream and butter. But it's not for everyone. And the ketogenic diet requires close monitoring by your doctor. Common side effects of these high-fat diets include:
  • Constipation
  • Nausea
  • Abnormal levels of blood lipids (such as cholesterol or triglycerides)
Rarer, but serious, side effects include kidney stones and pancreatitis (pancreas inflammation). What Can I Expect Looking to the Future? You can expect doctors and researchers to explore new ways to prevent seizures. These may include new medicines, surgical techniques or diets. I hope that this latest research will lead to a better understanding of why some people develop seizures in the first place. Perhaps that could lead to preventive approaches.  It's not clear to me why a high-fat, low-carb diet should help people with seizures. I hope future studies will determine why it works.]]>
Thu, 30 Oct 2014 00:00:00 -0400
Substance in Cocoa May Aid Aging Memories A substance found in cocoa may help to improve normal age-related memory loss, a very small study...                    What Is the Doctor's Reaction? Last night, my husband gleefully read me a headline from the New York Times:  "To Improve a Memory, Consider Chocolate." Throwing scientific caution to the wind, I said, "Sign me up!" By Monday morning, the article was the second most e-mailed on the New York Times website.  The Times was reporting on a very small study in a journal called Nature Neuroscience. The study was done at Columbia University and partially funded by the Mars candy company. It had only 37 participants. For 3 months, the study group drank a mixture that was high in an antioxidant called cocoa flavanols. Compared with a group who drank a lower-flavanol mixture, they did much better on specific memory tests. The study group did better on a kind of memory test that involves pattern recognition. They also had increased function in an area of the brain linked to this type of memory. It's important to note that they did not have a change in the part of the brain linked to early Alzheimer's disease. Flavanols are plant-based chemicals found in chocolate, tea and apples. They are a type of antioxidant. They may help to decrease other chemicals that can damage cells. No one is sure why flavanols had such a robust response in this study. Maybe they increased blood flow to the brain. Or perhaps they caused part of a nerve cell, called a dendrite, to grow and become better able to connect with other cells. Don't trade in your broccoli for a bag of dark chocolate just yet. Remember, this was a very small, early study. It's exciting in that the findings are so positive, but there are many reasons for caution:
  • Currently, to consume the amount of flavanol in the study, you’d have to eat about seven chocolate bars, with all their fat and calories.
  • This was a very, very small study. Studies like this are intended to show "proof of concept" -- that an idea is a good one. In order to really know about how this affects large groups of people, we would need to see a much larger study over a longer period of time.
  • Be aware that most chocolate is highly processed. The processing markedly decreases the amounts of flavanols in the final product.
As a doctor, I find this study really intriguing. First, it addresses a huge issue (and fear) for all of us -- memory loss as we age. Second, it offers an exciting new area for research. It doesn't give us answers, but it begs us to ask more questions.  Am I going out to buy flavanol pills? No. Will I watch with interest what larger, more comprehensive studies show? Absolutely. What Changes Can I Make Now? Age-related memory loss can be quite normal. Even some people in their 20s and 30s have an occasional moment where they can't quite find a word. As we get older, this can intensify. It's not a sign of impending Alzheimer's if you occasionally forget a word, lose your car in a parking lot, or forget someone's name and remember it later. The worrisome memory loss linked more with dementia is different. Signs of this type of memory loss include:
  • Forgetting ever having known someone
  • Losing the ability to drive a car or read a clock
  • Having significant trouble with math calculations
  • Having memory loss that causes you to be unable to do something you have done for years 
You can take other steps that might be more helpful for your memory than eating massive amounts of chocolate. Here are some ideas:
  • Be vigilant about your overall health. Get regular exercise, eat healthy foods and don't smoke!
  • Exercise your brain as well as your body. Play a game, or read and discuss a book, a movie or a sports event with someone else.    
  • Be social. Isolation can lead to depression, which can affect memory as well.
  • Sleep well.
  • Use tricks if you need them. Keep a calendar. Write notes to yourself.  Set a reminder on your phone. 
If you or someone you love has serious worries about memory, discuss it with a doctor. He or she will help you understand normal memory loss, review your medicines and perform some tests. All of this should help determine if there is a serious cause of memory loss. Some causes can be reversed. What Can I Expect Looking to the Future? These study results are really intriguing. We all want to preserve our memories and our functioning.  And, I suspect, most of us would like to see chocolate come out as a heroic contributor. I think that this study will lead to larger studies that will help us to answer important questions about the role of cocoa flavanols in memory retention.]]>
Tue, 28 Oct 2014 00:00:00 -0400
Better College Care Urged for Chronic Illness Most colleges say they can manage care for students with long-term medical conditions, a new study...
What Is the Doctor's Reaction? It's one of the triumphs of modern medicine: youth with chronic diseases are living longer and more normal lives. And more are going to college. The problem is that caring for them often falls apart there. It's no small task to give youth with chronic (long-term) disease normal lives. It often requires:
  • Daily medicines
  • Lots of appointments with doctors and other health professionals
  • Close monitoring by parents and school nurses
  • Adjustments in daily routines
Taking care of a chronic disease requires planning. It requires not only reacting to problems, but also preventing problems from happening. Pediatric practices have learned to do this. They have learned to teach parents and communities how to do it too. But colleges -- or at least most of them -- aren't set up to do it. That was the finding of a study just released in the journal Pediatrics, the official journal of the American Academy of Pediatrics. Researchers surveyed 200 colleges. They asked the colleges how they identify and care for students with chronic disease. They asked about three common chronic diseases: asthma, diabetes and depression. About 42% of the colleges did not have any system at all to identify and care for students with chronic disease.  Nearly one-third, 31%, did have a "registry," a list of students with chronic disease. They also had a system to do some outreach to them. While this is encouraging, 31% is nowhere near enough. In general, college health systems are set up to deal with infections, injuries and other emergencies. They aren't set up to do ongoing management of chronic illness. There is an assumption that parents and students will manage it. When students go to college near their homes and can continue to use their health care team, this is feasible. But when students go to college far from their homes, it's far more difficult. What Changes Can I Make Now? If you have a child with a chronic disease, you can do a lot to help him or her stay healthy at college. First and foremost, it's important to teach teens about their disease. They need to be empowered to take part in their own management. As tempting as it is to do everything for your child, it's important to remember that you won't always be at your child’s side. Taking a few steps can help your teen learn to take over management of his or her chronic illness. By high school:
  • Make sure your teen understands his disease: what it is, what causes it, what makes it worse and what makes it better. Don't assume that he knows already.
  • Make sure your teen knows her medicines and when to take them. Let her take them herself. As you transfer this responsibility, use pill boxes (the kind that have days written on them) or do daily checks on the counter on inhalers to make sure the medicine is being taken. But let her do it herself.
  • Let (or make) your teen do the talking at visits with health-care professionals
  • Give your teen some time alone with health-care professionals.
As your teen gets ready to go to college:
  • Talk to the college. Find out what health services it offers for students, and whether any system is in place for those with chronic disease. Make sure that the college knows your child's diagnosis. Make sure that a medical professional at the school is aware of your child's needs.
  • If your child needs specialty care, find specialists near the college that your child can see. Set up appointments, if possible. Get medical records sent to each specialist's office.
  • If your child is going to school outside of your state, talk to your insurance company. Make sure your child can get medical care in the area.  Most colleges offer a health plan for students, but it may not cover the medical care your student needs off-campus.
  • Talk with your insurance company about getting a 90-day supply of medicines.
  • Put everything in writing. This should include medicines, what to do in an emergency, numbers to call, etc. Give a copy to your child and one to the health staff at the college. For example, all students with asthma should have a written Asthma Action Plan.
What Can I Expect Looking to the Future? As the number of college students with chronic disease increases, colleges will need to work with doctors and parents to come up with systems to care for them. I hope that this study will be a wake-up call to many colleges, and will help to move that process forward.]]>
Mon, 27 Oct 2014 13:57:00 -0400
Rare Headaches May Be More Common after Weight-Loss Surgery Some people may develop headaches after weight-loss surgery, a small study suggests. The study...                    What Is the Doctor's Reaction? Low fluid pressure in the brain can cause headaches. It's a rare disorder, known as spontaneous intracranial hypotension. This study alerts us to the potential for these headaches to occur after weight-loss surgery. But they are still uncommon. Doctors often cannot find out the exact cause of headaches that don't go away or keep coming back. Because it is rare, spontaneous intracranial hypotension might not be considered. The brain and spinal cord are surrounded by fluid. This cerebrospinal fluid acts as buffer. It prevents the brain from bumping up against the skull and the spinal cord from pressing against the spine. The fluid is produced deep inside the brain. It fills cavities in the brain called ventricles. The fluid flows out to cover the brain and spinal cord. The brain constantly produces new spinal fluid. Special channels outside the brain absorb older fluid. Normally, new fluid is made and old fluid absorbed at a constant rate. So the pressure around the brain stays within a very narrow range. If the pressure gets too high or too low, it can cause headaches. High pressure around the brain is much more common than low pressure. Most often, high pressure happens because of some major problem such as a stroke, infection or brain tumor. But high pressure can happen without a known cause. It's called benign intracranial hypertension. Intracranial hypotension is the opposite condition. The fluid pressure around the brain and spinal cord is low. The usual cause is one or more small holes or tears in the layer of tissue that surrounds the spinal cord. The spinal fluid sits between the spinal cord and this layer. The holes let spinal fluid leak out, lowering the pressure. Most cases of intracranial hypotension occur after a spinal tap. This procedure is done to get a sample of cerebrospinal fluid for testing. The doctor needs to insert a needle through the covering tissue layer. The hole is small. It almost always seals right away after the procedure. Even with perfect technique, however, the hole might stay open. Fluid can continue to leak out. Intracranial hypotension is called "spontaneous" if low pressure develops around the brain when there was no prior spinal tap or direct trauma to the spine. In this small study, most of the patients with spontaneous intracranial hypotension were found to have leaks. Why this happened after weight-loss surgery is not clear. Of interest, the opposite problem, intracranial hypertension, also causes headaches. This happens most often in obese young women. To treat it, doctors may recommend weight-loss surgery. After surgery, there is often a dramatic fall in cerebrospinal fluid pressure and total relief of headaches. This is probably because small fluid leaks occur. What Changes Can I Make Now? The most common symptom of intracranial hypotension from low fluid pressure is a headache that gets worse if you remain standing. Lying down relieves the pain. Other symptoms may include neck pain or stiffness and nausea. Sometimes vomiting occurs. A new headache after a spinal tap is almost always caused by intracranial hypotension. The spontaneous ones can be more difficult to diagnose because not everyone has the classic symptoms. This type of headache can get better within a couple of weeks if you just spend more time lying down. But it may last for months and sometimes even years. If the pain is mild to moderate, conservative treatments are usually tried first. These include drinking plenty of fluids, adding salt to your diet and taking caffeine tablets. The usual dose of caffeine is 200 to 300 milligrams, taken 2 to 3 times a day. For headaches that are more severe or don't get better, doctors perform epidural blood patch therapy. It's a relatively simple procedure. About one teaspoon of your own blood is injected into the layer of tissue that holds in spinal fluid. The procedure is similar to the epidural injection of pain-relieving medicine used in surgery and childbirth. What Can I Expect Looking to the Future? If you are considering weight-loss surgery, the rare problem of intracranial hypotension should not be a reason to avoid it. But knowing ahead of time that the surgery could be the cause of a new headache would almost surely lead to quicker relief.]]> Thu, 23 Oct 2014 00:00:00 -0400 Quarantine Ends for Ebola Patient's Family Though they shared an apartment with the first Ebola patient who got sick in the United States,...                    What Is the Doctor's Reaction? We have so much to learn about the Ebola virus. This particular strain that is infecting people in West Africa seems to be especially dangerous. Yet research has shown that some people have Ebola viruses enter their bodies but do not get sick or have relatively mild symptoms. Why do people respond so differently? We have many more questions than answers. But experience with other infectious agents and some small studies of Ebola-infected patients provide a few clues. Ebola belongs to a family of viruses known as filoviruses. Ebola is not contagious until a person has symptoms. The virus is spread only through close contact with body fluids. The viral particles enter through the nose, mouth, lining over the eye or a break in the skin. Once inside the body, the Ebola virus multiplies very rapidly, producing millions and millions of viruses. The virus does damage in several ways. It can directly kill certain cells. It also can produce:
  • A substance that blocks the immune system from effectively fighting the virus
  • Another substance that latches onto cells that line the inside of blood vessels. These cells become fragile. It's the reason that bleeding often occurs with this infection.
How quickly and how vigorously the immune system revs up plays a major role in what happens next. Some people don't get sick or have only a flulike illness. That's because their bodies mounted a very quick, robust immune response to the virus. Those who develop more severe problems are most often otherwise healthy, but just don't have the same rapid, vigorous immune response. Obviously, people with known impaired immunity would have a very high risk of dying from Ebola virus infection. Other reasons (not proven) why direct exposure to the Ebola virus might not cause infection include:
  • The virus gets on normal intact skin only, without getting into the nose, mouth or eye.
  • The cells that line the nose, mouth and eye don't allow the virus to either latch on or get beyond the cell wall.
  • The virus gets inside the body. But the person has been exposed to some other strain of Ebola or another type of virus. This means that his or her immune system was already primed to fight the new Ebola virus invasion.
What Changes Can I Make Now? It's important to keep Ebola in perspective for people not living in West Africa. We have had four cases in the United States. And only one person died. Compare that to influenza. Flu viruses infect many millions of people every year and cause thousands of deaths. If you haven't had your flu vaccine yet, get it today. There are more options than ever. To help protect yourself from the flu, colds and other viral infections, wash your hands or use an alcohol-based cleanser frequently.  If you do get a viral infection, your body can fight it more effectively with a strong immune system. You can feel better faster and reduce your risk of serious illness. Following general health guidelines is the best step you can take toward keeping your immune system strong and healthy.
  • Don't smoke.
  • Eat a diet loaded with fruits and vegetables.
  • Take a multivitamin if you suspect that you may not be getting all the nutrients you need through your diet. For example, few foods naturally contain vitamin D.
  • Exercise regularly.
  • Get enough sleep.
  • Maintain a healthy weight.
  • Take steps to lessen stress.
The store shelves are loaded with herbs and supplements promoted to boost the immune system. But so far there is no evidence that they actually bolster protection against infection or disease. Showing whether an herb or supplement can enhance immunity is a complex task. For example, scientists don't know whether an herb that seems to raise the levels of one type of immune cell in the blood is actually doing anything helpful for overall immunity. What Can I Expect Looking to the Future? Ebola will be contained in the United States and in most other countries around the world. But the epidemic in West Africa will take many months to slow down. Meanwhile, vaccine studies are under way. And treatment with antibodies against Ebola has shown some early success.]]>
Wed, 22 Oct 2014 17:21:00 -0400
Study: Common Symptoms Often Not Explained At least one-third of patients who visit a doctor with common symptoms don't get a clear,...                      What Is the Doctor's Reaction? Did you ever see your doctor for something you thought might be serious? Did you leave the office with just reassurance, wondering if you needed some sort of treatment or test? You're not alone. But there are probably good reasons for your doctor's decision not to do too much right away. As this new study shows, most symptoms are not caused by  a serious condition. And most get better in a short time. In fact, an explanation often can't be found for some of the most common symptoms that bring people to their doctors. Among patients seeing a doctor, the most common physical symptoms reported are:
  • Pain. This accounts for about 50% of visits.
  • Respiratory complaints, such as congestion, colds or flu. They account for 25% to 30% of visits.
  • Other symptoms, including fatigue, sleep problems, intestinal symptoms or dizziness. They account for another 20% to 25% of visits.
The latest edition of the journal Annals of Internal Medicine published the study. Researchers reviewed previous research. They excluded respiratory symptoms, such as common colds that nearly always get better quickly on their own. Here's what they found:
  • One third or more of people with common symptoms will have no definite cause discovered, even with many tests.
  • Doctors ask about symptoms and perform a physical examination. This provides up to 94% of the information needed to establish a diagnosis or to rule out serious conditions. Tests may add little more.
  • Psychological symptoms often occur along with physical symptoms. And they can affect each other. Teasing them apart and diagnosing the cause of each may be impossible.
  • In up to 80% of cases, people with common symptoms recover within a few weeks or months. This happens even without a specific diagnosis or treatment.
  • It's rare that a serious condition not suspected at the first visit is diagnosed in follow-up.
  • Some treatments can be helpful for many different symptoms. For example, acetaminophen (Tylenol and generics) can be helpful for headaches, back pain or an achy shoulder, even if the cause of these symptoms is not clear.
  • An explanation itself can be helpful. Providing a possible cause may be more reassuring than throwing up one's hands and leaving it at "well, everything is normal."
These observations are vitally important for doctors who see patients with common physical complaints. But they are also important for patients who are worried about their symptoms. Of course, there are always exceptions. Sometimes there is a serious problem even when it was not suspected during the first visit. Such cases need follow-up and another evaluation. It's good to keep an open mind. But it's also important to know the facts. What Changes Can I Make Now? Based on the findings of this new review, perhaps the biggest change you can make now is to modify what you expect from your doctor. For example, if you have a headache, don't expect your doctor to get a CT scan right away (even if you are worried that you may have a brain tumor). Serious causes of headaches are rare. Most headaches have no obvious cause regardless of how many tests are done. But let your doctor know your concerns. Explaining why a serious condition is unlikely and why extensive testing is not necessary are important parts of your doctor's job. If you have a symptom that bothers you and won't go away, let your doctor know. After a thorough review of your symptoms and an examination, there's a good chance that your doctor can diagnose the cause. But don't be surprised if you get:
  • No diagnosis.
  • No testing.
  • No specific treatment (other than a pain reliever or other supportive treatment).
  • A recommendation to "give it some time."
  • An explanation about your symptoms that is more of a theory than proven scientific fact. For example, your doctor may tell you that stress and tension in the muscles of your neck may be causing your headaches.
If you're getting worse instead of better or the nature of your symptoms changes, it may be best to take another look. At that point, it may be time to order a test or two.  What Can I Expect Looking to the Future? Doctors often say "common things are common." That may seem obvious -- and redundant! The idea is that in most cases, it makes little sense in to go searching for rare conditions when a "garden variety" diagnosis is so much more likely.  The findings of this new review explain how true this is. Amid concerns about too many treatments and too many tests, health-care costs keep going up. We would all do well to recognize that time, not extensive testing and treatment, is often the best medicine.]]>
Tue, 21 Oct 2014 00:00:00 -0400
Seeing Film Violence May 'Desensitize' Parents As they watch more violence or sex in movies, parents may be less bothered by it and more likely...                    What Is the Doctor's Reaction? Do you check what a movie is rated before letting your child watch it? The Motion Picture Association of America (MPAA) rates movies. This system is intended to give useful information to parents about the movie content.
  • General Audiences (G): Anyone can see the movie.
  • Parental Guidance Suggested (PG): Some parts of the movie may not be right for young children to see.
  • Parents Strongly Cautioned (PG-13): Some parts of the movie may not be right for children under 13 to see.
  • Restricted (R): Children under 17 must be with an adult.
Over the years, this system appears to have changed. Rating decisions seem to be made sometimes by chance. The ratings do vary a lot. The amount of violence and sex in movies that can be seen by younger children has gone up. Parents also seem less worried about their children seeing these risky behaviors in movies. How come? A new study in the journal Pediatrics might help explain these trends. Researchers wanted to know if parents have a less emotional reaction to the violence and sex in movies when they see them more often. This is called being "desensitized" -- the more they see it, the less it bothers them. To test this idea, 1,000 parents of children and teens, ages 6 to 17, were asked to watch 6 movie clips in a row. The clips showed violence or sex from popular movies. For each clip, they were asked:
  • The youngest age they thought was OK for a child to see the movie
  • If they would let their own child watch the movie
The more clips parents watched, the more they thought the scenes were OK for children to see.
  • The youngest age they thought was OK for a teen to watch violent or sex scenes dropped from 17 to 14.
  • Parents became more willing to let their own children watch each movie.
Parents also were less bothered by:
  • Violence if they had watched more movies in the last week
  • Violence and sex if they had already seen the movies from which the clips were taken
So is all PG-13 content acceptable for teens? This study suggests that movie ratings probably are not so clear or strict. Many parents may be quicker to accept these ratings if they are desensitized to violence and sex themselves. The parents hired by the MPAA to help decide movie ratings also are probably desensitized to violence and sex, the researchers say. After all, these parents watch hundreds of movies a year. What Changes Can I Make Now? Risky behaviors in movies can affect your child more than you might think. For example, a large body of research has linked watching lots of violence with more aggressive behavior in children. Or if characters engage in sex, teens may see it as exciting and something they want to try. It is your job to make sure your child is watching movies and using other media that are right for his or her age. Be sure to follow these tips:
  • Work to understand the social and emotional development of your child or teen.
  • Know all the different types of media your child uses and sees every day.
  • Insist on a good balance among your child's activities.
  • Make a family plan for movies to watch and safe ways to use all technology.
  • Limit how much time your child spends seeing movies, watching TV and surfing the Internet.
  • Talk often with your child about the dangers of violence, sex and other risky behaviors seen in movies or through technology.
  • Do not rely on movie ratings.
    • Learn more about the movie to decide what is right for your child to see.
    • Know that there may not be any difference in the amount of violence and sex shown in movies rated PG-13 rather than R.
    • Do not watch movies or TV shows you do not think are OK for your child in front of him or her.
What Can I Expect Looking to the Future? The increasing amount of violence and sex in popular movies is cause for concern. More research is needed on the effect of violence and other risky behaviors in movies on children's future behavior. Parents should make their own informed decisions on what movies their children watch. We also need to take a new look at the movie ratings system. It does not appear to be so effective in protecting youth from being exposed to problem content that could have a negative effect on their health. Future studies should explore potential improvements to the system. These could include:
  • Ways to prevent desensitization in movie raters
  • The effect of recruiting more parents to participate in the rating system
Mon, 20 Oct 2014 00:00:00 -0400