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 Thu, 18 Dec 2014 13:47:00 -0500 Fitness Linked with Lower Blood Pressure; Being fit reduces the risk of high blood pressure, a large new study finds. The study included...                    What Is the Doctor's Reaction? High blood pressure (hypertension) is among the most common long-term (chronic) illnesses that can be cured or effectively treated without medicines.  And yet, much of what you hear about treatment is focused on medicines.  High blood pressure affects up to 40% of the population. So the drugs that help lower it are among those most widely prescribed worldwide.  Prevention and control are important because high blood pressure increases the risk of heart attack, stroke and other heart and blood vessel diseases. A new study makes the case that a high level of physical fitness dramatically lowers your risk of high blood pressure. The Journal of the American Heart Association published the study. The study was large. It analyzed data from more than 57,000 people.  Sixty percent of them had high blood pressure. Researchers measured people's fitness with a treadmill test. Then they looked at the relationship between fitness and the diagnosis of high blood pressure. Here's what they found out:
  • More than 70% of those with a low level of fitness were diagnosed with high blood pressure.
  • Less than 50% of those with a high level of fitness had been diagnosed with high blood pressure.
  • Those with a high level of fitness had a 20% reduction in the risk of having high blood pressure.
  • During the 18 years of the study, newly diagnosed high blood pressure was more common among those who weren't fit (49% of new cases) than among those who were highly fit (21% of new cases).
These findings remained even after researchers accounted for other factors that affect high blood pressure risk. The factors included age, ethnic group and excess weight. Of course, the idea that exercise might be good for blood pressure is not new. But this is among the best studies showing just how good it can be. The message of this research is clear: avoiding high blood pressure is one more reason to commit to being fit. What Changes Can I Make Now? The health benefits of exercise are many. Recent research has made the list even longer. Besides its impact on blood pressure, getting regular exercise has been linked with:
  • Improved mood
  • Higher level of energy
  • Better cholesterol levels
  • Lower risk of diabetes
  • Fewer heart and circulation problems such as heart attack or stroke
  • Lower risk of certain cancers, including cancers of the breast and colon
  • Better brain function in advanced age
  • Better sexual function (among men)
The ideal type and amount of exercise is not clear. But most experts suggest exercising most days of the week for at least 30 minutes. About 45 minutes to an hour might be even better. Exercise should be at least moderately intense. Brisk walking is a good example. With the New Year approaching, resolve to become more active. Consider making these changes:
  • Start slow. Then slowly increase how long or how intensely you exercise. For example, if you can walk half a mile in 20 minutes without difficulty, try to walk six-tenths of a mile in the same time. Or walk a few minutes longer instead. Each week, increase your distance or how long you exercise by no more than 10% to 15%.
  • Try to vary your exercise routine. This will reduce the chance that you will lose interest and quit.
  • Make exercise a routine part of your day, and make it a priority.
  • Get an exercise partner. This makes exercise a social activity, and you can encourage each other. Exercise will likely be more enjoyable, and you'll be less inclined to skip it.
  • Increase your "non-exercise" activity. For example, take the stairs instead of the elevator.
If you have any concerns about whether it's safe for you to exercise, ask your doctor. It might be best to meet with a physical therapist before getting started. Together you can design a safe exercise program filled with activities you enjoy. Finally, get your blood pressure checked. High blood pressure usually causes no symptoms. So the only way to know if your blood pressure is in a good range is to have it measured. This is true even if you are physically fit. In this latest research, a full 20% of the newly diagnosed cases of high blood pressure were among those with the highest levels of fitness. What Can I Expect Looking to the Future? You can expect researchers to continue to look at the relationship between exercise and blood pressure. For example, it would be helpful to know if the exercise itself prevents high blood pressure. It's possible that people who exercise have other healthy habits that protect them. As scientists continue to analyze the impact of exercise on health, I believe the list of benefits will get even longer. What's harder to predict is whether we will respond by doing what it takes to become more fit.]]>
Thu, 18 Dec 2014 13:47:00 -0500
Studies Suggest E-cigarettes May Aid Quitters E-cigarettes may help smokers to quit, a new report concludes. But it noted that there's not much...                    What Is the Doctor's Reaction? Smokers know well that the best thing they can do for themselves and the people around them is to quit. But the nicotine in cigarettes is viciously addictive. People who have been hooked on both nicotine and narcotics commonly say cigarettes are the harder habit to kick. E-cigarettes have been suggested as a potential therapy to help current smokers quit. These battery-operated, cigarette-shaped devices give off a vapor that contains nicotine. E-cigarettes don't have all the toxic ingredients found in tobacco smoke. So they are generally perceived to be a healthier choice than regular cigarettes. Nicotine replacement with a vapor would seem to be as safe as nicotine in a patch or gum. A Cochrane review published today suggest that, in the short term, e-cigarettes may indeed safely help people to quit smoking. Cochrane is nonprofit international group. It regularly evaluates the best evidence regarding health questions. This is done by panels of researchers, health professionals and patients. They are selected based on expertise and interest. They must have no commercial bias and no conflicts of interest. The Cochrane conclusion about e-cigarettes was based on just 2 clinical trials. They included 662 smokers. People were randomly assigned to use either e-cigs or devices that had a similar look and taste but contained no nicotine. The trials compared smoking quit rates after a year. About 9% using the real e-cigarettes were not smoking after a year. Only 4% of those who used the fake e-cigs remained nonsmokers that long. Some people could not quit completely. Among this group, the ones who used the real e-cigs were more likely to cut way down on regular cigarettes than people who used the nicotine-free devices. The Cochrane analysis also looked at observational studies. These studies look at what happens when people choose a particular behavior or treatment. The studies also suggested that e-cigs could safely help smokers quit. Observational studies don't offer the same high level of evidence as clinical trials. What Changes Can I Make Now? The two main challenges to quitting smoking are:
  • Overcoming the nicotine addiction
  • Breaking the smoking habit
Overcoming the nicotine addiction. Nicotine replacement therapy doubles your chances of quitting successfully. It can help you get through the cravings. Nicotine replacement therapy delivers a low dose of nicotine into the bloodstream. This eases, or even erases, withdrawal symptoms. Unlike smoking, nicotine replacement produces relatively constant blood levels of nicotine. It doesn't have the toxic chemicals in tobacco. I would still recommend the more time-tested nicotine replacement products
  • Patches
  • Gum
  • Nasal sprays
  • Inhalers
  • Lozenges
If you do opt for e-cigs as a nicotine replacement tool, you must use them much as you would use other nicotine products. That means not smoking traditional cigarettes. Keep in mind that e-cigs are meant only as a transition to NO nicotine. For most people, nicotine replacement therapy is not enough. They also need a prescription medicine. These medicines act on the brain. They decrease the cravings for nicotine and reduce withdrawal symptoms. The two that doctors prescribe the most are varenicline (Chantix) and bupropion (Wellbutrin, Zyban). Varenicline works in two ways. It partly imitates the effects of nicotine. This cuts down cravings and withdrawal symptoms. It also partially blocks the effect of nicotine, causing a smoker to get less of a reward. Bupropion is an antidepressant that also helps reduce the desire to smoke. It likely works because the bupropion and nicotine both stimulate the release of the same brain chemicals. Breaking the smoking habit. When smokers quit, they need to finds ways to fill the void. They need ways to break the rituals, daily habits, social encounters and emotionally charged moments that can trigger the impulse to light up. Behavioral therapy, smoking cessation programs and support groups can help. Your best chance of success is to commit to doing both things at once:
  • Lessen the nicotine withdrawal symptoms.
  • Make changes in behavior to break the smoking habit.
What Can I Expect Looking to the Future? Recently, great concern has been raised about potential harmful effects from some of the flavor enhancers and other chemicals in e-cigarettes. The Food and Drug Administration currently does not regulate e-cigarettes. More studies also need to be done to look at even the short-term safety of these devices to help smokers quit.]]>
Wed, 17 Dec 2014 13:56:00 -0500
Study: People Care about Uses of Medical Data People may be more willing to share their health records for research than for marketing, a new...                    What Is the Doctor's Reaction? Often, when I read or listen to the news, I hear about electronic breaches of privacy. Recent issues have come up from big box stores, social networks and credit cards. Many people are attuned to this fact of modern life. So they do what they can to protect their privacy. But few of us think about these issues with respect to our own health information. The Affordable Care Act encouraged most doctors to use electronic heath records. They contain a huge amount of information. Using data from electronic records can be a boon for medical researchers. They can get a lot of data about a lot of people. Not surprisingly, corporations are interested in this information, too. It can help them better target and sell their products to groups of people. How do people feel about the privacy of their medical records? Is it OK to use this information, combined with that of others, for research? Is it OK to use the information, combined with that of others, for marketing? When would you want to give consent to a researcher or a university? A company? The authors of a new study set out to find the answers.  Researchers from the University of Pennsylvania and Parkland Health System in Dallas did the study. They wanted to find out what really mattered to people about the use of their health information. They began the project by considering two points of view:
  • Some people will think that no health information should be shared without consent.
  • Others will feel that the value of what we learn from large numbers of records might trump a person's right of privacy.
They study included a diverse group of people. The authors gave them several different scenarios for potential use of health information. They reacted to scenarios involving consent for the use of patient information for research or for marketing.  Not surprisingly, people felt that privacy was important. Yet they had a nuanced response, possibly more so than the authors expected. They felt that the reason for the use of the information mattered. They considered the use of information for marketing without consent least appropriate. They felt that using information for research and obtaining consent was much more appropriate.  Views about consent were similar for whites, Hispanics and African Americans. Minorities felt that use of health information for marketing was more appropriate than whites did. This study furthers our national conversation. Previous research and editorials have focused largely on obtaining consent. This study tells us that consent remains important. But patients are clearly interested in the reason for use of their information. They feel that it is more appropriate when the information is used for research -- arguably of higher social value -- than for marketing. What Changes Can I Make Now? Do not fear your doctor's electronic health record. Research shows that electronic records can help improve both patient safety and communication between health professionals.  Our medical world has become ever more complicated, with information from many sources. Keeping it in an electronic record makes sense.  Records are set up to remain safe and confidential. They do an excellent job of that.  To learn more about how your health system uses its records, you can ask your doctor. Chances are that you signed a consent form for receiving care at your doctor's office or hospital. Those consent forms state whether or not your information might be used for research purposes. This will be grouped together with the information of others, not identified as yours. The most important thing to do now is to be aware that researchers, people interested in medical ethics and even companies are talking about this topic. Speak up if something is important to you. What Can I Expect Looking to the Future? I think we can expect to see more discussion and debate about the use of collected medical information.  I suspect we will also see some missteps and errors as we move toward an understanding of whether and how to share medical data for research and marketing purposes.]]>
Tue, 16 Dec 2014 00:00:00 -0500
Compound May Help Reduce Weight Gain In early testing, a new compound appeared to help reduce weight gain, researchers said. The...                    What Is the Doctor's Reaction? Many overweight people who go on a diet are successful in the short term. But almost all of them gain back those pounds one to two years later. Often they end up even heavier than when they started. After weight loss, it's important to maintain a lower-calorie diet and get more exercise. Except for surgery, there is no other proven safe and effective way to prevent weight gain. But results of a study done at the Imperial College in London suggest there may be such a therapy in the future. When bacteria in the lower intestine (colon) break down fiber, short-chain fatty acids are produced. One of them, called propionate, triggers the release of two hormones that suppress appetite. Propionate alone, taken by mouth, is not an option. Even in large doses, it would get absorbed rapidly in the small intestine. So it would never make it all the way down to the colon.  These researchers developed a compound containing propionate that is not absorbed by the small intestine. They combined it with inulin, a plant fiber. Once the compound reaches the colon, the bacteria easily break it apart to release the propionate. The researchers first confirmed that the inulin-propionate compound did result in a higher blood level of the hormones that suppress appetite. Then they studied the short-term effect on healthy human volunteers. The volunteers did not notice a decreased appetite, but their meal sizes were smaller. The researchers next did a 24-week study of 60 overweight adults. Half took the inulin-propionate compound. The other half took an inulin-placebo compound. In the longer-term study, the people taking the propionate did report decreased appetite. They also were less likely to gain weight than those taking the placebo. The possibility of a safe supplement to prevent weight gain is very exciting. However, it's important to point out the limitations of this early study. It included only a small number of people. Those who got inulin-propionate in the short-term study did not notice an appetite change. (Those in the 24-week study did, however.) It's also possible that weight-gain differences between the two groups occurred by chance and were not related to the compound. What Changes Can I Make Now? High-fiber diets have been promoted to help decrease weight gain. And eating more fiber and drinking extra water surely does help some people avoid weight gain. The current theory is that fiber helps control weight because you fill up with food that has fewer calories per ounce. But this new report suggests there may be a more significant effect of eating more fiber. Could just eating more fiber lead to higher amounts of propionate in the colon and less weight gain? Theoretically, it's possible. But you would need to eat would be much more than the usual high-fiber diet provides. This almost surely would cause belly pain and too much gas. Also, the amount of propionate produced in each person would be unpredictable. I recommend a modified diet both for weight loss and weight maintenance:
  • As many vegetables daily as you want. They are a great source of fiber.
  • Lots of fruits, but more vegetables than fruits.
  • Olive oil for salads and cooking.
  • One handful (about 1½ ounces) of nuts, 2 to 3 times per week. Nuts are healthy, but if you eat too many the calories add up quickly.
  • Plenty of legumes (beans, peas and lentils), at least 3 times per week.
  • Whole grains as your main carbohydrate source.
  • Three or more servings of fish (especially fatty fish) a week. A serving is 4 ounces.
  • A cup of low-calorie yogurt daily.
  • If you enjoy alcohol, limit yourself to 1 (for women) or 2 (for men) drinks a day. One drink is 5 ounces of wine, 12 ounces of beer or 1½ ounces of liquor.
Specifically avoid:
  • Soda and sugary drinks
  • Sweets, pastries and commercial bakery goods
  • Red and processed meats (eat white meats instead)
  • Margarines and most tub spreads
What Can I Expect Looking to the Future? A larger, long-term study is needed to confirm whether this inulin-propionate compound is safe and effective as part of a weight-management strategy.]]>
Fri, 12 Dec 2014 13:21:00 -0500
Study: Gout Attacks Increase at Night Gout attacks are more than twice as likely to occur overnight as during the day or evening, a new...                    What Is the Doctor's Reaction? It's rare that your doctor can predict the time of day your illness will start. But with gout, it is possible. Gout develops because of the buildup of a normal waste product, uric acid. Crystals of uric acid can deposit in the joints. This causes a sudden attack of arthritis. Other problems linked to excess uric acid include kidney stones and lumps of uric acid (called tophi) that deposit in the skin or elsewhere. Many people think gout is a disease of antiquity, yet it is still quite common. It affects an estimated 4% of the U.S. adult population. That's more than 8 million people. A new study found that gout attacks are more than twice as likely to occur during the night or early morning as during the day. The idea that gout may attack in the middle of the night is not entirely new. In fact, doctors noticed this centuries ago!  Consider this classic quote from the noted 17th century doctor Thomas Sydenham: "The victim goes to bed and sleeps in good health. About two o'clock in the morning he is awakened by a severe pain in the great toe; more rarely in the heel, ankle or instep. This pain is like that of dislocation. . ." However, the timing of gout attacks has not been well-studied until now. This new study is remarkable for two reasons. It not only studied the question of when gout attacks occur, but it did so by using the Internet. People with gout (previously diagnosed by a doctor) signed up online. Then they provided information about their attacks through the research study's website. The researchers found that among 724 people with gout:
  • An attack of arthritis caused by gout was 2.4 times as likely to happen overnight (midnight to 8 a.m.) as during the day (8 a.m.  to 4 p.m.).
  • An attack of arthritis was 1.3 times as likely to occur during the evening (4 p.m. to midnight) as during the day.
  • The risk of a gout attack at night was higher even among those who avoided known triggers (such as alcohol) in the 24 hours before the attack.
Is this information helpful? That's hard to say (and it's not something that this study can answer). These findings could lead doctors to recommend that their patients with gout take preventive medicines late in the day or in the evening. It's possible this approach would be more effective than standard treatment. What Changes Can I Make Now? You can make changes to reduce your risk of gout. Some health factors increase the risk of gout. These risk factors include:
  • A high intake of certain foods and drinks. Examples include organ meats (such as liver), seafood, alcohol and high-fructose corn syrup. Consuming less can lower the risk of developing gout.
  • Obesity. Excess weight loss is strongly linked to the risk of gout. Weight loss can reduce this risk.
  • Certain medicines. A common example is diuretic medicines for high blood pressure or leg swelling. Stopping these medicines or switching to a different drug (with the approval of your doctor) may lower the risk of gout.
  • Kidney disease. Taking measures to keep your kidneys healthy can lower gout risk. Good control of blood pressure is one important measure.
If you have already been diagnosed with gout, you can take medicines to treat attacks. They include:
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen
  • Colchicine
  • Corticosteroids
For those with frequent or severe gout attacks, medicines to lower uric acid may be recommended. They include:
  • Allopurinol
  • Febuxostat
  • Probenecid
  • Pegloticase
With lifestyle changes and these medicines. most people with gout can put a stop to the arthritic attacks. But the first step is diagnosis. So let your doctor know if you have painful swelling of a joint. The sooner you are evaluated, the more likely it is that a diagnosis can be confirmed. What Can I Expect Looking to the Future? You can expect future research to show why gout attacks tend to occur in the middle of the night. The authors of this research suggest several possible reasons. They include:
  • Lower body temperature at night
  • Mild dehydration during sleep
  • Reductions in the hormone cortisol during sleep
  • Lower oxygen levels related to sleep apnea (a common condition among people with gout)
Each of these could contribute to increased formation of uric acid crystals in joints. These crystals cause gout attacks. Finding out why gout tends to flare up at night could lead to better ways to prevent or treat the disease.]]>
Thu, 11 Dec 2014 14:03:00 -0500
Flu May Be Severe, Shots Less Effective A strain of influenza that often causes severe disease is the one seen most often so far in this...                    What Is the Doctor's Reaction? The only thing constant is change itself. This was the wisdom of Heraclitus, a Greek philosopher. But the idea of change is enough to make flu vaccine manufacturers crazy. Constant change of the influenza (flu) virus makes it hard to provide a perfect flu shot. This season, the standard flu vaccines are made to protect against 4 strains of flu. The high-dose flu shot for adults over 65 has 3 strains. The U.S. Centers for Disease Control and Prevention (CDC) just issued a report about early cases seen in this flu season. Just over half (52%) of the 85 virus samples collected had a flu strain that was not included in any of this year's vaccines. The "interloper" strain is H3N2, part of a family called influenza A. In the past, H3N2 strains have been capable of causing fairly severe flu illness. This strain of flu isn't going to match the antibodies that people make after getting this year's flu shot. So it is possible that the shots will fail to prevent many cases of flu this year. How did we go wrong? Really, researchers and vaccine makers can't be blamed. Staying ahead of the flu is in some ways a game of odds and guessing. There is careful science behind the vaccine, but the flu can surprise us in any year. Scientists from the World Health Organization (WHO) plan each year's vaccine. Scientists in 83 countries keep track of flu infections around the world. They sample and analyze the strains that are causing infections. In order to plan a vaccine for the Northern Hemisphere, scientists track flu between September and January. This shows which strains have caused the most widespread and severe infections. Scientists also know which strains are the newest. This is important, because few people are likely to be immune to these strains. By February, the scientists issue a report. Vaccine makers use it to develop updated vaccines. In most years, the flu shot protects against 70% to 90% of circulating flu virus infections. In particularly bad years, the flu shot is less than 50% effective. What Changes Can I Make Now? If you have not yet received the flu shot this year, should you skip it? No, get the vaccine. Most flu seasons have several strains of flu that create trouble. It is still very early in flu season. The strains included in this year's vaccine may begin to circulate more widely. The vaccine will allow us to prevent at least those strains. Should we lose faith in the process for updating the vaccine each year? No, it truly is an incredible accomplishment that we can protect ourselves against the flu virus as well as we do. Flu vaccine has saved many lives. If you do get the flu this year or any year, please try to avoid exposing others. Take a few days off work, wear a mask and wash your hands. Most people who develop the flu do not need to visit their doctors. If you are short of breath and have flu symptoms, you should be examined. Before you arrive, tell the doctor's office staff that you may have the flu. They may be able to advise you about your symptoms over the phone, with no visit. If you come in to the office, you may be provided with a mask for the time you are in the waiting area. Antiviral medicines such as oseltamivir (Tamiflu) don't help much to shorten flu symptoms in people who are otherwise well. But they might prevent a hospital stay or severe illness from flu. Antiviral medicine for flu is recommended for people who are under age 2, over age 65, have weaker immune systems or have chronic (long-term) illness. Tamiflu must be started within 48 hours of when symptoms start. It is not likely to help if you don't have a fever. About 17% of people who take Tamiflu have a side effect of vomiting. It is reasonable to take this drug if you get the flu. However, it is reasonable to go without it, too. What Can I Expect Looking to the Future? Some parts of the flu virus vary less from strain to strain than others do. "Conserved proteins" on the virus surface seem to carry forward even when a strain mutates. These proteins are found in almost every strain of flu. Researchers are racing to develop a universal flu vaccine. If a vaccination could target these conserved proteins, it may prevent all types of flu. A universal flu vaccine might protect us longer than a year, and might require boosters only every few years. Progress toward a universal vaccine is being made in Italy, Israel and California. Early tests are promising. The Food and Drug Administration has not yet granted approval. It will probably be several more years before a universal flu vaccine is available.]]> Fri, 05 Dec 2014 00:00:00 -0500 Study: Longer Surgery Increases Clot Risk Being in surgery for a longer time may increase the risk of forming a dangerous blood clot, a new... Being in surgery for a longer time may increase the risk of forming a dangerous blood clot, a new study suggests. Researchers looked at information about 1.4 million people. All of them had surgery under general anesthesia in a 6-year period. Those surgeries were done at 315 hospitals. After surgery, just under 1% of the patients developed blood clots. About 0.7% developed a clot in the body's deep veins. This is called a deep vein thrombosis. Most of these clots occur in the legs. About 0.3% of those in the study developed a pulmonary embolism. This is a clot that travels to the lungs. Clots were 27% more likely to occur after the longest surgeries than after average-length surgeries. The risk of clots was lowest after the shortest surgeries. The journal JAMA Surgery published the study online. HealthDay News wrote about it December 3. What Is the Doctor's Reaction?
When it comes to medical "facts," many are actually unproven. Doctors often make decisions based on long-held assumptions. Though they seem to be correct, many have never been well-studied. A new study is a good example. It looked at whether the amount of time you are in surgery affects your risk of forming blood clots in the legs or lungs. These clots can be dangerous. Clots in the legs can travel to the lungs. Inside the lungs, clots can prevent oxygen from getting into the blood. Large or multiple clots in the lungs can be fatal. Doctors have long believed that the longer the surgery, the higher the risk that clots will form. Until now, though, high-quality research on this has been lacking. The medical journal JAMA Surgery published the new study. Researchers gathered data from 1.4 million people who had general anesthesia and surgery. The operations occurred at more than 300 hospitals between 2005 and 2011. Here's what the study found:
  • About 1 in 100 surgeries were followed by blood clots. About one-third of the clots were in the lungs. The rest were in the legs.
  • Those with the longest operations had a 27% higher risk of blood clots than those whose surgery was of average length.
  • People with operations that took the least time had a 14% lower risk of clots.
This research doesn't prove that a longer operation actually causes blood clots. However, the findings suggest that they might. Will these findings change anything? That depends on whether we can:
  • Find ways to shorten surgery
  • Use blood thinners more effectively to stop blood clots from forming
  • Discover why a longer operation increases the risk of blood clots
If we can do these things, perhaps we can reduce the impact of this dreaded problem. That would be a big deal. In the United States, more than half a million hospital admissions and 100,000 deaths each year are linked to blood clots that occurred after surgery.  What Changes Can I Make Now? You can make changes to reduce your risk of developing a potentially serious blood clot. Here's what you can do:
  • Let your doctor know of any personal or family history of abnormal blood clots. This is especially important if you are considering surgery.
  • Avoid medicines linked with a higher risk of blood clots. These include drugs that contain estrogen.
  • Avoid sitting for long periods. For example, walk around often during long plane flights. Take frequent breaks during long car trips.
  • Drink plenty of liquids, especially when you travel long distances.
  • Avoid long periods of bed rest. For example, if you are in the hospital, get up and walk around as much as you are able.
If you have symptoms that might be caused by a clot in a leg vein or the lungs, see your doctor right away. Worrisome symptoms include:
  • Unexplained leg swelling, especially if it affects only one leg (or one leg much more than the other)
  • Unexplained leg redness, pain or warmth
  • Shortness of breath
  • Chest pain, especially if it's worse when you take a deep breath
  • Fainting
  • Coughing up blood
These symptoms would be of even greater concern if you have:
  • A history of abnormal blood clots
  • A condition (such as cancer) that makes you prone to clotting
Many conditions other than blood clots in the legs or lungs could account for these symptoms. But, if you have any of the symptoms, it's worth getting an exam from your doctor.  What Can I Expect Looking to the Future? You can expect doctors and researchers to get better at preventing, detecting and treating blood clots in the legs and lungs. In recent years, several new blood thinners have been developed and approved. More are on the way. This new research suggests that shorter surgeries may help prevent blood clots. So it's possible that surgeons will soon find ways to reduce the time it takes to safely complete the most common operations. I hope that researchers will figure out why longer surgeries seem to increase the risk of blood clots. Answering this question could lead to better preventive measures. And that's important because some operations simply can't be completed any faster.]]>
Thu, 04 Dec 2014 12:46:00 -0500
Hospital Errors Reduced, Report Says Preventable hospital deaths are occurring less often, a new report says. The government's Centers... Preventable hospital deaths are occurring less often, a new report says. The government's Centers for Medicare and Medicaid Services did the report. It was based on medical records. The agency focused on preventable infections, drug errors and falls in hospitals. It found that 17% fewer of these problems occurred in 2013 compared with 2010. That trend led to 50,000 fewer deaths. About 1.3 million fewer people developed infections and other problems that were acquired in the hospital. Fewer errors also led to a $12 billion drop in avoidable hospital costs, the report said. But 10% of hospital patients were still affected by some sort of error. The Associated Press and Reuters Health news service wrote about the report December 2. What Is the Doctor's Reaction?
If you had asked doctors before 1990 how often major errors occurred in their hospitals, the answer would have been "rarely." But that year a study was published that looked at "adverse events" in hospitals throughout New York State. The study cast the first light on how big the problem actually was. Nine years later, the problem became a national discussion when the Institute of Medicine (IOM) published the report "To Err Is Human." The IOM estimated that as many as 98,000 people died each year as a result of medical mistakes in U.S. hospitals. That's more than the number of Americans who die from breast cancer and traffic accidents combined. The 1999 estimate by the IOM may have actually been too low. In 2010, less than ideal hospital care was estimated to contribute to 180,000 deaths of patients covered by Medicare. We need to be careful when comparing these statistics. For example, it's misleading to compare the IOM number of preventable hospital deaths and the 2010 estimate of hospital deaths potentially related to care issues. The 1999 IOM report looked at preventable errors as a direct cause of deaths. The 2010 number looked at the contribution of less than ideal care. These are not the same. Many of the people receiving "suboptimal" care would likely have died even with ideal care. Whatever happened between 1999 and 2010, the good news is the progress made in the last 3 years. A new government agency report gives the numbers. In 2013, less than ideal care resulted in 50,000 fewer hospital deaths than occurred in 2010. What Changes Can I Make Now? You can do a lot to help yourself or a loved one stay safe in the hospital. It starts with engaging the nurse. He or she will be with the patient all day or all night. Talk with the nurse soon after admission to the hospital. This way it won't seem like you are challenging the care delivered. More and more doctors and nurses realize that involved patients and families help to decrease errors and prevent further health problems. Here is a checklist of standard questions for all patients in hospitals:
  • What medicines are currently ordered? What does each one do? It's important to ask because it may not be on your record if you have had an adverse reaction to one of the medicines. Also, you might ask if you really need all of those pills.
  • Is the patient receiving blood clot prevention? People in the hospital are at increased risk of blood clots forming in the legs. Medicines, mechanical devices on the legs or both can help to prevent clots.
  • Can any of the tubes be removed today? The tubes may include intravenous lines as well as catheters to drain urine. Keeping the number of tubes going into the body to a minimum helps to decrease infection risk.
  • Does the patient need to be kept in a certain position in bed? For example, raising the upper body may help with breathing or help avoid the backup of stomach contents into the lungs (aspiration).
  • How often does the patient need to be turned from one side to the other? Ask the nurse if you can safely turn your friend or family member in the bed. Frequent turning helps avoid bed sores.
  • Can I help get the patient out of bed? This question prompts everyone to work with the patient to get him or her moving.
  • What should visitors do about hand cleansing? Feel free to make sure that all hospital personnel wash their hands before touching the patient.
You will have other specific questions and concerns. Express them, and always finish with, "How can I help?"   What Can I Expect Looking to the Future? It's somewhat reassuring that hospitals are getting safer. Improved systems are helping to avoid drug errors, and there's a greater emphasis on infection control. But these measures can only go so far. Patients and their loved ones need to actively participate to stay safe.]]>
Wed, 03 Dec 2014 00:00:00 -0500
Study: Statins Don't Protect Bones Contrary to some earlier research, a large new study concludes that statins do not reduce the risk...                    What Is the Doctor's Reaction? Cholesterol-lowering drugs called statins reduce the risk of heart attack and stroke. And they can prevent the most common cause of heart disease -- blocked coronary arteries. Previous studies suggested another possible benefit of taking a statin. Statin drugs appeared to reduce the risk of fractures related to thin bones (osteoporosis). The link between statins and bone health made sense. Statins calm inflammation and improve the flow of blood through small blood vessels. Both of these factors could help keep bones strong. But the studies suggesting this bone health benefit were observational studies. These types of studies look at what happens when people choose different behaviors or treatments. They cannot prove a cause and effect. In this case, something else that's different between the people who took a statin and those who didn't might be the real reason for fewer fractures. Now we have a well-done clinical trial addressing this question. People were randomly assigned to take a daily pill of rosuvastatin (Crestor) or a placebo. The study showed that this statin does not reduce fracture risk. Clinical trials are considered the gold standard for medical evidence. It's extremely likely that other statins also do not prevent thin bones and reduce fracture risk. But that's OK. We have other excellent ways to prevent and treat thin bones. The important take-away from this trial is that statins also don't increase fracture risk. New guidelines suggest that millions more people should be taking a statin. They may be taking it for the rest of their lives. So proof that statins don't harm bone health is very reassuring. What Changes Can I Make Now? Don't rely on your statin to help keep your bones strong. Here is what you can do to prevent osteoporosis and fractures:
  • Exercise regularly. Choose exercises that permit you to bear your full weight. Walking is an excellent choice.
  • Choose exercise that takes place outdoors, since sunlight exposure is one way you can increase your vitamin D level. Vitamin D is necessary for bone growth and repair.
  • If you don't get frequent sun exposure, you likely need to take a vitamin D supplement. The Institute of Medicine recommends:
    • 600 international units (IU) of vitamin D a day for everyone ages 1 to 70
    • 800 IU of vitamin D a day for those 71 and older
  • Eat a diet rich in calcium. About 1,000 to 1,200 milligrams per day is enough for most adults.
  • Don't smoke.
  • Drink only small or moderate amounts of alcohol. This means up to one drink per day for women and up to two drinks a day for men.
  • If you know your bone strength is low, ask your doctor about medicines that have been proven to help build bones.
  • Discuss with your doctor how to avoid falls, especially if you have had a fall. Your doctor might:
    • Suggest a home safety evaluation
    • Make a change in medicines if one of them causes you to feel lightheaded or affects your balance.
What Can I Expect Looking to the Future? Statins have an excellent long-term safety record. But with so many people taking them year after year, researchers need to keep looking for potential undiscovered side effects of statin drugs.]]>
Tue, 02 Dec 2014 13:57:00 -0500
Half Million Cancers a Year Tied to Obesity Nearly half a million cancers worldwide each year are linked with excess weight, a new study...                    What Is the Doctor's Reaction? Imagine that researchers have discovered a way to prevent half a million cases of cancer each year. And what if the preventive treatment required no surgery, costly treatments or high-tech equipment? And wouldn't it be remarkable if the screening test for these cancers was as simple as stepping on a scale? In fact, excess weight does increase the risk of cancer. Most people don't realize that. When people think of risk factors for cancer, they probably think about:    
  • Smoking and its link to lung cancer
  • Sun exposure and how it can increase the risk of skin cancer
  • Genetics and how some cancers run in families
But being overweight or obese can increase your risk of several types of cancer. The new study examining this issue analyzed the impact of weight trends between 1984 and 2012 on obesity-related cancer rates. Researchers looked at 184 countries. Here's what they concluded:
  • Each year, excess weight is responsible for 481,000 cases of cancer worldwide. That's nearly 4% of all new cancers diagnosed.
  • Obesity-related cancers are more common in women (5.4% of new cancers) than men (1.9%). The difference is largely due to cancers of the uterus and breast.
  • More of these new cancers were diagnosed in developed countries. Nearly 2 out of 3 were diagnosed in North America and Europe.
  • Obesity-related cancer rates varied by country and gender. For example, among men in the Czech Republic, 5.5% of new cancer cases were obesity-related. For women, the highest rate was in Barbados (13%).
These findings are surprising -- and alarming. But they also show an opportunity. Many cancers have no known preventive measures. These cancers do. What Changes Can I Make Now? Change how you think about excess weight. It's much more than just the way you look. It can have an enormous impact on health. As noted in this latest research, excess weight increases the risk of several cancers. They include:
  • Breast, ovary and uterus (among women after menopause)
  • Colon and rectum
  • Esophagus
  • Kidney
  • Pancreas
Excess weight also contributes to the risk of:
  • Heart disease
  • Type 2 diabetes
  • Stroke
  • High blood pressure (hypertension)
  • High cholesterol
  • Osteoarthritis
  • Sleep apnea
  • Gall bladder disease
  • Liver disease
  • Depression
Losing excess weight isn't easy. That's probably clear to anyone who has tried. So avoiding excessive weight gain in the first place is especially important. Calculate your body mass index (BMI). This is a measure of weight adjusted for height. If you're currently at or near your ideal BMI (less than 25), balance your calorie intake with calories burned to keep yourself at a healthy weight.  These steps also can help you to avoid weight gain:
  • Choose a healthy diet that is low in saturated and trans fats and high in fiber and whole grains.
  • Pay attention to portion size.
  • Eat only when you're hungry.
  • Increase your activity level by changing your everyday activities (such as taking the stairs rather than the elevator) and by exercising regularly.
For people who are already overweight or obese, it's important to cut calories and exercise more to lose the excess pounds. In some cases, medicines (such as orlistat) may be an option. Surgery may be recommended for "morbid obesity" (with a high BMI and medical problems related to obesity). If you are above your ideal body weight, talk to your doctor about a weight loss program that's best for you. What Can I Expect Looking to the Future? Unfortunately, obesity has become an epidemic in many countries. That will likely contribute to an increase in obesity-related cancers, as well as diabetes and other health problems.  We know more now about the health problems linked with obesity. I hope that as this awareness spreads, we'll be able to slow and even reverse the rising rates of obesity. It's also likely that future research will reveal why excess weight increases cancer risk. A better understanding of this connection could lead to new ways to prevent and treat cancer.]]>
Wed, 26 Nov 2014 00:00:00 -0500
Study: Yogurt May Reduce Diabetes Risk A cup of yogurt a day may help keep diabetes away, a new study suggests. But the reduction in risk...                    What Is the Doctor's Reaction? There's more good news about yogurt. A previous study showed that among all of types of foods eaten daily, yogurt was linked with the least risk of weight gain. Now a new study shows that a serving of yogurt each day may help you prevent type 2 diabetes.  There has been concern that eating a lot of dairy products might lead to type 2 diabetes. The new study used information gathered from three large, long-term studies of health professionals to help answer this question. The researchers found no link between eating any amount or type of dairy products and a higher risk of type 2 diabetes. What they did find is that people who reported eating yogurt regularly developed type 2 diabetes less often than those who were not yogurt eaters. It's not known why eating yogurt would reduce the risk of type 2 diabetes. Surprisingly, there was no body weight difference between those who did or didn't eat yogurt. Perhaps the probiotics in yogurt alter the mix of bacteria that live in our intestines. This might mean that the bacteria would use more sugar. That would leave less sugar to be absorbed into the body. The results of this research need to be interpreted with caution. This was an observational study. This type of study looks at what happens when people choose different behaviors or treatments. It cannot prove a cause and effect. In this case, something else that's different between the people who did and didn't eat yogurt might be the real cause. What Changes Can I Make Now? These are the best ways to prevent type 2 diabetes:
  • Maintain a healthy weight.
  • Stay physically active.
  • Dedicate time to exercise each day.
Besides eating yogurt, people who are most successful at keeping their weight in check eat more:
  • Vegetables
  • Fruits
  • Whole grains
  • Nuts
On the other hand, lifestyle choices linked to the greatest weight gain include:
  • Eating potato products, especially potato chips and French fries
  • Consuming sweetened drinks and foods
  • Drinking alcohol
  • Watching television
  • Getting less than six hours or more than eight hours of sleep per night
What Can I Expect Looking to the Future? Type 2 diabetes starts with resistance to insulin. Insulin becomes less effective at moving sugar out of the blood stream and into our cells. Could yogurt keep our cells more responsive to insulin? Future studies will help us answer this question.]]>
Tue, 25 Nov 2014 14:24:00 -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