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, 26 Feb 2015 00:00:00 -0500 Wider Spread for Hospital-Linked Infections In a recent year, more than 450,000 Americans had a type of severe diarrhea that most often occurs... Clostridium difficile (C. diff) bacteria. These infections are hard to cure. Researchers used information from 2011. They looked at C. diff infections in 10 states. Two-thirds of them occurred in hospitals and nursing homes. The other one-third occurred in the community. But 80% of the community patients had been to see a doctor or dentist recently. Most of them received antibiotics. C. diff bacteria are most likely to grow and produce toxins when antibiotics kill the normal, harmless bacteria in the intestine. The New England Journal of Medicine published the study. HealthDay News wrote about it February 25.                    What Is the Doctor's Reaction? Clostridium difficile (C. diff) is the No. 1 cause of death from intestinal infection in the United States. The number of new cases of C. diff continues to rise. And that means the number of deaths will also increase unless we can reverse the upward trend. C. diff bacteria, and the spores they produce, are found widely in the environment. The spores can hang around on your hands and all kinds of surfaces. The spores are not active until they get inside your intestine. If you swallow the spores, they might come to life. In healthy people, this is rarely a problem. But in some cases, C. diff can cause trouble. It most often happens after you take antibiotics. The stronger the antibiotics and the longer you take them, the greater the risk that C. diff will get active. When you take an antibiotic, it doesn't kill just the bacteria that are causing an infection, such as pneumonia. It also can wipe out the good bacteria that always live in the large intestine. These good bacteria crowd out any C. diff bacteria that may exist there. They don't allow C. diff to become active. When antibiotics wipe out the good bacteria, C. diff can take over and make lots of toxins. C. diff might not get active enough or produce enough toxins to cause any symptoms. But, in large amounts, C. diff toxins can injure the lining of the lower intestine (colon). When symptoms do occur, they can range from mild to severe. Sometimes the condition can be life-threatening. In the past, almost all cases of C. diff developed in hospital patients. These are still the people at highest risk. But now more cases are being diagnosed outside the hospital. Some occur in people who have recently been in the hospital. This study estimated that 82% of the C. diff patients who are not in the hospital visited a doctor or dentist within the last 3 months. It's likely that the majority of people with C. diff received a prescription for an antibiotic. What Changes Can I Make Now? Your personal risk of getting C. diff diarrhea is low, even if you have taken antibiotics. But here are some ways that you can help combat this rising health problem:
  • Wash hands thoroughly with soap and water for at least 15 seconds. This is the best way to stop the spread of C. diff (and many other dangerous organisms). It's especially important to wash your hands after visiting a hospital or any health-care facility. Alcohol-based cleansers do not get rid of the C. diff spores.
  • Take antibiotics only if you really need them. Common colds and most sore throats and sinus infections are caused by viruses. Antibiotics only kill bacteria.
  • Sometimes you need to be in the hospital. But as soon as you feel well enough, find out if home health care is an option for you. The shorter your hospital stay, the lower your risk of coming in contact with C. diff spores.
Many people who take antibiotics have mild diarrhea. C. diff is rarely the cause. However, if you have abdominal pain, fever or very frequent loose stools, contact your doctor right away. What Can I Expect Looking to the Future? Preventing C. diff is a national priority. Until a vaccine becomes available, we need to slow the number of cases. This will require:
  • Maintaining isolation of infected patients in the hospital and nursing home
  • Strict hand washing by hospital staff after leaving the patient's room
  • Decreasing the use of antibiotics when they are not needed
On the treatment front, "poop pills" will become a more standard therapy. The pills contain feces from a donor that are processed so there's nothing left but the bacteria. These are the good bacteria that can crowd out the C. diff bacteria and halt the symptoms.]]>
Thu, 26 Feb 2015 00:00:00 -0500
Study Tallies Painkiller Risk after Heart Attack Some common painkillers may increase the risk of second heart attacks when taken along with drugs...                    What Is the Doctor's Reaction? We take NSAIDs so often that we forget they have the potential to be dangerous. That's especially true after a heart attack, according to results of this study. NSAID stands for nonsteroidal anti-inflammatory drug. These drugs include over-the-counter ibuprofen (Advil, Motrin and others) and naproxen (Aleve and others). They also include prescription drugs such as celecoxib (Celebrex). Patients who have had a heart attack are told to take a daily aspirin to help prevent a second heart attack. Aspirin attaches to blood cells called platelets to make them less sticky. This decreases the risk of blood clots forming in heart arteries. Sometimes, doctors also prescribe a second anti-platelet drug, such as clopidogrel (Plavix). This is standard care if you have had a procedure called angioplasty and stenting. A balloon is inflated inside an artery to open it. Then the stent, a wire mesh tube, is placed inside to keep it open. Some people may need a third so-called blood thinner if they also have an abnormal heart beat known as atrial fibrillation. The use of any anti-platelet drug, even a baby aspirin, increases the risk of bleeding inside your body. When you add a second or third blood-thinner, the risk rises even more. NSAIDs are well known to also increase bleeding risk. Taking one of them when you also need to take aspirin, another blood thinner or both further raises the risk. The results of this study show this combination can be especially dangerous for people who have had a heart attack. If they bleed, their chances of dying are much higher if they are taking an NSAID as well as a blood thinner. The researchers also found that people who use NSAIDs after a heart attack are more likely to have another heart attack or stroke. This might seem odd, given that most heart attacks and strokes are caused by blood clots. After all, NSAIDs generally make it harder for blood clots to form. Taking them along with an anti-platelet drug should further reduce the risk of clots. The exact reason for the higher chance of heart attack and stroke with NSAID use is not clear. But many other studies have found a similar link. What Changes Can I Make Now? Getting safe pain relief can be a challenge if you are taking an anti-platelet drug or another type of blood thinner. Here are some ideas: Start with a non-drug approach. Try a heating pad, ice or physical therapy, if appropriate. Even if these approaches don't take away your pain, they may let you take a lower dose of a painkiller. Use acetaminophen. Acetaminophen (Tylenol, generic versions) may be an alternative to an NSAID. However, you must limit your use of this drug if you have a liver problem or some other conditions. A safe amount is 3,250 milligrams per day. That's no more than 10 regular-strength or 6 extra-strength tablets spread out over 24 hours. Acetaminophen reduces fever and pain. It does not reduce inflammation. For people with arthritis, reducing inflammation is usually important, so this option won't work for everyone. Consider other NSAID alternatives. Non-acetylated salicylates are cousins to aspirin. They include salsalate (Disalcid) and choline magnesium trisalicylate (Trilisate). These drugs may provide pain relief and reduce inflammation somewhat. Use the safest NSAID. Some NSAIDs may be less risky than others. The prescription NSAID diclofenac (Voltaren) appears to have the highest risk for a second heart attack. Some studies suggest that naproxen (Aleve, Naprosyn) has the lowest risk. Take your aspirin first. Aspirin prevents clotting that can lead to a heart attack. Some studies suggest NSAIDs may interfere with aspirin's protective effect. So, if you have heart disease and must use an NSAID, take the aspirin first. Wait an hour. Then take your required dose of the NSAID drug. Use only what you need. Take the lowest effective dose of an NSAID for the shortest period of time. However, in this study, even three days of use increased the chance of bleeding. What Can I Expect Looking to the Future? Sometimes there's no good alternative to an NSAID for treating pain in someone who has had a heart attack. In this case, many heart specialists recommend naproxen. Most studies suggest that naproxen is safer for the heart than other NSAIDs. But this is not proven. For now, the U.S. Food and Drug Administration requires that naproxen carry the same warning as other NSAIDs do.]]> Wed, 25 Feb 2015 00:00:00 -0500 Hospital 'Superbug' Outbreak Linked to Scopes About 100 patients at a Los Angeles hospital may have been exposed to dangerous drug-resistant...                    What Is the Doctor's Reaction? Newspapers are describing an infection that has appeared in a Los Angeles hospital as "nightmare bacteria" and a "superbug." Two of the seven patients have died. The hospital has contacted other recent patients in a search for more cases. The outbreak is an infection known as CRE, which stands for carbapenem-resistant Enterobacteriaceae. CRE bacteria make a digestive enzyme of sorts that can break apart one of our strongest antibiotics. Where I work, the antibiotic carbapenem has been compared to an "atomic bomb" because it can kill almost any infection. But carbapenem doesn't kill CRE. Neither do the other antibiotics in the same class.  In fact, most of the antibiotics we reach for to treat infections are useless against CRE. Infections like this are sometimes called multi-drug resistant. Are we out of options? No, we still have a plan for patients with CRE. But treating it does present challenges. We have some antibiotics that can still work against CRE infection. The hospital lab needs to run some tests to see which ones might work well. Doctors usually use at least two antibiotics at the same time to fight this infection. In most cases, we use three or more. CRE is a dangerous family of infections. Some people who are infected die. But it is not extremely contagious. This helps a lot.  The "E" in "CRE" is actually a family of bacteria. Some members of the family you might recognize are salmonella and E. coli. Another common one is named Klebsiella. Only a few strains of salmonella, E. coli, and Klebsiella are CRE. Most of them are easily treated with antibiotics. A couple of bacteria types outside of the "E" family are also multi-drug resistant in the same way. Doctors often call them close relatives of the CRE family. These include a few strains of Pseudomonas and Acenetobacter. What Changes Can I Make Now? CRE has been around for some years now. This is not the first time we have had a hospital outbreak of it. And we know what to do to stop an outbreak like the one in Los Angeles. Doctors need to isolate patients who have CRE diagnosed, so it does not spread through the hospital. You don't need to do anything special to avoid CRE infection. Just take good care of your health. Most people who get CRE have been sick, and have needed to take frequent antibiotics. In a study of almost 100 people who had a CRE infection, 86% had been treated with a powerful antibiotic called a cephalosporin in the previous 3 months. Other factors that increase the risk of this infection include:
  • Having a serious illness
  • Needing to wear a urinary catheter
  • Having a long-term intravenous (IV) line
  • Getting breathing support from a ventilator
  • Having traveled to India or Pakistan
What Can I Expect Looking to the Future? This outbreak of CRE in Los Angeles is bad news. But it is not likely to become a more widespread problem, now that doctors know what they are dealing with. We have seen other hospitals go through larger outbreaks, and those outbreaks ended. For example, a hospital in Colombia had 54 cases of CRE. That outbreak was stopped after intensive cleaning of the hospital, replacement of several sinks and decontamination of stethoscopes. The larger lesson in CRE is that we need to be careful to use antibiotics in just the right way. We should take antibiotics when we need them, and avoid them at all other times. Otherwise, we allow resistant bacteria types to develop. Doctors have only a small number of strong antibiotics in our "back pocket" for infections like CRE. Researchers are working to develop new antibiotics that can kill resistant bacteria. But that takes time, and drug-resistant bacteria keep popping up. We are in a close race.]]>
Fri, 20 Feb 2015 16:55:00 -0500
Study Links Virus to Giant Cell Arteritis A new study links the shingles virus to another painful condition in the elderly, giant cell...                    What Is the Doctor's Reaction? It's not often that researchers discover a new cause of an old disease. But that could be exactly what's happened with a disease called giant cell arteritis. It's a potentially serious disease. It can cause vision loss, unexplained fevers and other health problems. The condition affects adults over the age of 50.  It develops in 1 in 500 people in this age group. The cause of giant cell arteritis is unknown. It is considered an autoimmune disease. That means it develops when a person's immune system mistakenly attacks normal parts of the body. One theory suggests that the immune system is genetically wired to misfire and then something in the environment triggers the attack.  Prior research has searched without success to find an infection-related cause of giant cell arteritis. But a new study may be on to something. Doctors diagnose giant cell arteritis by examining samples from the temporal arteries. These are small blood vessels in the face, just under the skin of the temples. In the new study, researchers looked for signs of varicella-zoster virus (VZV) in these arteries. This is the virus that causes shingles. After a person recovers from chickenpox (varicella), the virus can lie dormant in nerve fibers. It can reactivate later in life to cause shingles (zoster). Results of the study appear in the medical journal Neurology. Researchers found evidence linking VZV infection to giant cell arteritis:
  • Among 82 people who developed giant cell arteritis, 61 (74%) had signs of VZV in the temporal artery.
  • Of the 61 temporal arteries that showed signs of VZV, 32 had nearby muscle tissue available for analysis. Nearly 40% of them also showed signs of VZV.
  • Of 13 people of similar age who died without a history of giant cell arteritis, only 1 (8%) had evidence of VZV infection in the temporal arteries.
Does this mean varicella-zoster virus is the cause of giant cell arteritis? Not quite. It's possible that something about this disease (or its treatment) could allow the virus to appear even if it had nothing to do with the disease. This study did not look for other possible causes, such as other infections. So it's also possible that some other condition alters the immune system of people with giant cell arteritis. In this case, VZV would be just "along for the ride." We need more research to confirm these results. Still, this study raises the exciting prospect that:
  • VZV may be a cause of giant cell arteritis
  • Antiviral medicines, such as acyclovir, may help to treat it
  • Vaccinations already available may reduce the risk of giant cell arteritis
What Changes Can I Make Now? In my view, it's too soon to make any changes based on this research. For example, it is too early to recommend treatment with antiviral medicines. We already can treat giant cell arteritis with corticosteroid drugs. It's also possible to prevent some further problems caused by this condition. If you are over the age of 50 and have symptoms that suggest giant cell arteritis, contact your doctor right away. This condition can cause sudden vision loss. Once lost, vision is rarely recovered.  Symptoms of giant cell arteritis include the sudden development of:
  • Headache
  • Jaw pain after chewing
  • Scalp pain
  • Unexplained fever
  • Changes in vision
  • Aches in the shoulders and hips
Having these symptoms doesn't mean you have giant cell arteritis. Each of them can also be explained by other conditions. But it's a good idea to get checked out if one or more of these problems arise. You may be able to reduce your risk of infection with varicella-zoster virus and any illness it may cause. Here's what you can do:
  • Get vaccinated against chickenpox. The vaccine, usually given in childhood, is likely to reduce the risk of shingles in adulthood.
  • Get vaccinated against shingles. The Zostavax vaccine is approved for people age 50 or older. Current guidelines recommend getting the shot at age 60 or older. However, some people should not get this vaccine. They include people with suppressed or impaired immune function.
  • If you develop shingles, take an antiviral medicine. These medicines include acyclovir (Zovirax), famciclovir (Famvir) and valacyclovir (Valtrex). If taken within 72 hours of when a rash appears, the medicines may speed recovery a bit. They also may reduce the risk of post-herpetic neuralgia. This is a long-lasting pain condition that can follow a shingles infection.
What Can I Expect Looking to the Future? The prospect of finding a cause for a mysterious condition is exciting. To identify a cause that we can prevent and treat is even better. In the near future, look for reports of more research that confirms (or disproves) the findings of this latest study.]]>
Thu, 19 Feb 2015 18:42:00 -0500
Tools May Calculate Heart Risk Too High Calculators used to assess people's risk of heart problems may put those odds too high, a new...                    What Is the Doctor's Reaction? For anyone who's had a heart attack or stroke, taking a statin makes a lot of sense. That's also true for anyone who has arteries narrowed by fatty build-up. Statins lower LDL ("bad cholesterol"). They slash the risk of future problems and deaths for these groups by more than 20%. But what about everyone else? New guidelines from the American Heart Association (AHA) and the American College of Cardiology (ACC) suggest using a risk calculator to determine who should take a statin. It is intended to be used for healthy adults ages 40 to 75. The calculation is based on:
  • Age
  • Gender
  • Race
  • Cholesterol levels
  • Blood pressure
  • Known diagnosis of diabetes
  • Smoker vs. nonsmoker
The calculator estimates your risk of having a heart attack, stroke or other forms of blood vessel disease in the next 10 years. If the chance is greater than 7.5%, the advice is to take a statin. Not so fast, a group of researchers says. Their new study finds that this and other calculators can overestimate risk of heart problems or stroke by a lot. The estimates can be as much as 67% too high for women and 154% too high for men. The researchers also looked at an alternative risk calculator called the Reynolds Risk Score. This one calculated the risk for men only about 9% too high. However, it estimated the risk for women 21% too low. How could the risk calculators be so inaccurate? One problem is that age matters the most in the equation. Once you hit age 64, everyone meets the criteria based on age. But we know that many 64-year-olds have normal blood pressure, excellent cholesterol levels and a very low risk of heart disease. The AHA-ACC risk calculator also does not take into account family history. This could lead to a risk estimate that is too low. Your numbers might be excellent. But if one of your parents was diagnosed with heart disease before age 50, that puts you at higher-than-average risk. You might benefit from taking a statin. What Changes Can I Make Now? You don't need a calculator if you are at least 40 years old and have diabetes. You should take a statin. Your risk of heart disease is 2 to 4 times higher than the risk for people without diabetes. A very high LDL level, at least 190 milligrams per deciliter (mg/dL), is another solid reason for taking a statin to lower heart disease and stroke risk. A very high risk score makes it easy to advise statin treatment. But what if your score puts your 10-year risk at 7.5% or just slightly above it? Should you take a statin? I plan to still use my patients' LDL cholesterol level as a guide. For my patients who have a high LDL, but one that is less than 190 mg/dL, I will recommend a Mediterranean-style diet and exercise. Both of these may help to lower LDL. Lifestyle changes should always be a priority, even if you need a statin. If the LDL is still greater than 160 mg/dL, I will likely suggest taking a statin drug. At lower LDL levels, I still may advise statin therapy for someone with a family history of heart disease at an early age. What Can I Expect Looking to the Future? Despite its limitations, the AHA-ACC risk calculator is an easy way to start thinking about your heart health and stroke risk. Bring your score next time you visit your doctor. It's an excellent tool to help you and your doctor devise a personal wellness plan. Even if your risk score is low, a healthy diet and exercise can do more than just protect you from heart disease. They also help decrease your risk of dementia and some types of cancer.]]>
Wed, 18 Feb 2015 00:00:00 -0500
For Many, Hot Flashes Last 7 Years For at least half of women with frequent hot flashes, the symptoms go on for more than 7 years, a...                    What Is the Doctor's Reaction? How long will this go on? It's a question that women suffering with hot flashes and night sweats ask often. And the answer varies; it can be quite hard to predict. But a new study is trying to provide a better answer. Doctors call them "vasomotor symptoms." Whatever you call them, they are common. Up to 85% of women have these sudden episodes of intense warmth and sweating around the time of menopause. The cause isn't known, but the leading theory is that it's caused by a reduction in estrogen. For some women, these symptoms are a minor annoyance. For others, they disrupt sleep and reduce quality of life. Estimates for how long symptoms last vary widely. They may begin 2 to 3 years before menopause. They may last for less than a year or more than 15 years. A new study examined how long hot flashes lasted among nearly 1,500 women who reported frequent symptoms. Here's what the researchers found:
  •  The median amount of time hot flashes and night sweats occurred was 7.4 years. The median is the midpoint of a set of numbers. This means that half of the women reported symptoms for more than 7.4 years!
  • When symptoms began while women were still having periods, they lasted for a median length of nearly 12 years. But when symptoms started after menopause, they lasted only about 3 years.
  • Hot flashes lasted longer for women who:
    • Developed symptoms at a younger age
    • Had less education and more stress
    • Were most bothered by the symptoms
    • Reported more symptoms of depression and anxiety
  •  Hot flashes also lasted longer for some ethnic groups than for others:
    • Japanese and Chinese women, about 5 years
    • Caucasian women, 6.5 years
    • Hispanic women, about 9 years
    • African-American women, about 10 years
These results surprised me. Symptoms lasted much longer than I had been taught. However, keep in mind that these women had severe symptoms. To be included in this study, women had to have at least six days of symptoms in the last two weeks. It's possible that women with less frequent symptoms also would have reported having them for fewer years.  While helpful, these results will come as cold comfort to the millions of women wishing their hot flashes would stop. The results of this study suggest that, for many of these women, relief is years away. What Changes Can I Make Now? If you have hot flashes, they are probably the result of hormone changes around menopause. Still, talk to your doctors about your symptoms. Other conditions can cause hot flashes. Men can develop hot flashes as well, especially when testosterone levels drop suddenly. This may follow treatments for prostate cancer to reduce testosterone. Ask your doctor what you can do about hot flashes:
  • Wait for them to go away. If symptoms are mild, you may decide just to put up with them. Each one will usually go away in a few minutes. Eventually, they will stop altogether.
  • Take steps to reduce symptoms. For example, you can lower the room temperature, use fans and wear loose-fitting layers of clothing that can be easily removed. Drinking cool water at the start of a hot flash also may help.
  • Avoid caffeine, alcohol and smoking.
  • Get regular exercise.
  • Take hormone-replacement therapy. This isn't for everyone, especially women with a history of breast cancer, heart disease or stroke. But it may be a reasonable option for many women. Use the lowest effective dose for the shortest time possible to relieve symptoms.
  • Try non-hormonal drug options include gabapentin, paroxetine or citalopram.
  • Take natural remedies. It's uncertain how effective these may be, but some experts recommend black cohosh and soy.
For each of these, other factors will affect any decision about treatment. Other medical conditions and other medicines are among the most important. But you and your doctor also will consider how severe your symptoms are and how much they affect the quality of your life. How long you can expect hot flashes to continue is another important thing to consider. And that's where this new study offers some insight. What Can I Expect Looking to the Future? This new study suggests that hot flashes may go on for quite a while. Here's what it doesn't tell us:
  • Why do they occur?
  • Why do they last longer and cause more misery for some women than for others?
  • How long can women with mild symptoms expect them to last (since this study only included women with severe symptoms)?
  • How can you safely prevent or treat hot flashes?
For answers to these questions, we'll need more research -- and more time.]]>
Mon, 16 Feb 2015 00:00:00 -0500
Hormones May Boost Ovarian Cancer Risk Using hormones to treat menopause symptoms may increase the risk of ovarian cancer, a new study...                    What Is the Doctor's Reaction? I am a primary-care doctor. I am also a middle-aged woman, and I am getting close to menopause. I have heard from many patients that it is unbearable to go through hot flashes. This makes me dread having them myself. So when there is medical news about menopause treatments, I think of my patients and I think of myself. And I read every word of it. A new study shows that estrogen treatment after menopause is linked to a higher chance of getting ovarian cancer. In fact, the study says, using estrogen for 5 years could cause 40% more cancers in the ovary. Wow, that sounds scary enough to give me a hot flash even without menopause. But this number is not as bad as it probably sounds to you. Why? First, this 40% increased risk applies only during the years you take estrogen. Once you stop taking estrogen, your risk starts to fall back toward average. For example, according to this study, by the time you are 5 years out from your estrogen treatment, the risk is only 10% higher than average. Second, ovarian cancer is a bad cancer, but it is pretty rare. In the United States, a woman has about a 1 in 4,000 chance of getting ovarian cancer during her 50s.This is the age when menopause needs treatment. So, if you decide to take estrogen for hot flashes, your risk while you are taking treatment is increased to about 1 in 2,900. This is about the same chance you have of being struck by lightning in your lifetime. (That risk, according to National Geographic News, is 1 in 3,000.) You should not lose sleep over this. What Changes Can I Make Now? Menopause hot flashes are an abrupt feeling of warmth in the chest and face, with sweating or pink skin. After a hot flash, the body temperature is low because heat has been lost. Then you might shiver or feel chilled. Hot flashes can bother your sleep. Some women wake up many times in a single night. When they happen a lot, they can really interfere with the quality of your life. Estrogen stops hot flashes. We used to think that estrogen prevented heart disease, but we don't think that anymore. Doctors stopped recommending estrogen as a long-term treatment because it increases the risk of blood clots, stroke, heart attack and breast cancer. But estrogen doesn't cause so much risk in women who are still in their early 50s, at menopause age. For most women, it looks safe (and very helpful!) to take estrogen around the time of menopause. The exceptions would be women who have a history of breast cancer, blood clots or heart disease. You shouldn't take estrogen for more than five years. The new worry about ovarian cancer probably will not change my mind about estrogen for most of my patients. But if you have a family history of ovarian cancer, estrogen might not be a good idea. I will continue to recommend estrogen for my patients who have very bothersome hot flashes. And if they bother me, I might choose to use estrogen myself. But what if your hot flashes last for more than five years? For some women, they do. This gets harder. Your risks of breast cancer, heart disease and stroke get bigger as you get older. Estrogen that is combined with progesterone may have the biggest risks (especially for breast cancer and heart disease). But estrogen without progesterone can cause uterine cancer. Most doctors avoid prescribing estrogen for longer than five years. If you have been taking estrogen for longer, it is best to try to reduce and stop the medicine. Estrogen is the best treatment for hot flashes, but a few other drugs might help. Examples are venlafaxine (Effexor), paroxetine (Paxil), citalopram (Celexa) and escitalopram (Lexapro). Don't stop estrogen abruptly. Your doctor can help you to gradually lower the dose. Otherwise, you are more likely to have hot flashes as you stop. What Can I Expect Looking to the Future? We need better treatments to manage menopause symptoms for women who:
  • Have hot flashes for five years or longer
  • Can't take estrogen because of cancer or other health reasons
One treatment that is being explored is a nerve-block injection. There is a cluster of nerves in the neck, called the stellate ganglion, that seems to be important to spreading the symptoms of a hot flash. In a study last year, injecting a local anesthetic into a specific area in the neck seemed to help hot flashes. We might hear more about this new treatment idea, if research confirms that is it safe and helpful.]]>
Fri, 13 Feb 2015 00:00:00 -0500
Stem-Cell Transplants Show Promise for MS Transplants of their own stem cells may help people with multiple sclerosis (MS), a small new...                    What Is the Doctor's Reaction? Multiple sclerosis (MS) is a disease of the brain and spinal cord that often leads to disability and early death. It is thought to develop because the immune system mistakenly attacks the nervous system. Treatments to suppress the immune system can help. But there's no known way to prevent MS, and no cure. Current treatments may work poorly, cause troublesome side effects or both. So it's worth taking note of news about a treatment for MS that may be more effective than what is available now. A new study compared stem-cell transplants with an older drug, mitoxantrone. All 21 people in the study had severe MS. It was getting worse despite standard treatments to suppress the immune system. Researchers have just published the study results in the journal Neurology. Nine people had stem cells removed from their bone marrow. Then they had immune-suppressing treatments, and the stem cells were injected again through a vein. The rest of those in the study received similar immune-suppressing drugs, followed by mitoxantrone. People were monitored by a neurologist and by MRI scans over four years. People treated with their own stem cells:
  • Were just as likely to become more disabled as those receiving mitoxantrone.
  • Had far fewer new areas of brain injury related to MS noted on brain scans.
  • Had no new MS-related inflammation in the brain. About 56% of the mitoxantrone-treated patients had new areas of inflammation, as shown on MRI. None of the stem-cell group had these new areas.
  • Had no permanent side effects related to treatment.
It may seem odd that the brain scans of those treated with stem cells appeared so much better than the other group, but their disability grew worse at the same rate. There are several possible explanations for this:
  • The study was too short. In a longer study, disability may have grown worse more slowly.
  • The study was too small. A larger study might have been able to detect better function over time. The study authors think this is the most likely explanation.
  • MRI results over several years may not be a reliable way to assess improvement in people with severe MS.
This study suggests that stem-cell transplants might be helpful for severe MS, but doesn't prove it. So it's hard to know how important this study is. But the results are promising enough that it should encourage more research. What Changes Can I Make Now? If you have symptoms of MS, see your doctor. Symptoms include:
  • Poor coordination or unsteady gait
  • Vision problems, such as double or blurred vision
  • Problems with speech
  • Pain or numbness in the face
  • Problems with urine control
  • Numbness, tingling or weakness in the arms and legs
These symptoms can develop for other reasons. So, if you have one or more symptoms, don't assume you have MS. If you have been diagnosed with MS, more treatments are available now than in the past. Treatment options include:
  • Corticosteroids
  • Interferon beta
  • Glatiramer
  • Dimethyl fumarate
  • Teriflunomide
  • Natalizumab
  • Alemtuzumab
  • Cyclophosphamide
Don't expect your doctor to recommend stem-cell transplants yet. It's simply too soon to know if the potential benefits are worth the risks. If you have MS, consider enrolling in a clinical trial. This is a way to advance medical science and have access to medicines that may be helpful but are not otherwise available. What Can I Expect Looking to the Future? In the future, you can expect researchers and doctors to expand the use of stem-cell treatments for many diseases, including MS. Stem-cell treatment is already common in some cancers, including certain types of leukemia and lymphoma. Future research should help us understand whether stem cell treatment:
  • Helps in early disease. MS symptoms may come and go. It's possible that stem-cell treatment will prevent symptoms that go away from coming back.
  • Helps for milder disease. This study only included people whose disability, on average, required them to use a cane or crutch.
  • Helps older adults with MS. The average age of people in this new study was 36 years old.
It's possible that the benefits linked with stem-cell treatment in this study are limited to making the brain scans look better. Larger and longer-term studies should clarify whether stem-cell treatment actually helps people live longer and better.]]>
Thu, 12 Feb 2015 00:00:00 -0500
Iron Pills Aid Recovery for Blood Donors Taking iron pills can help restore hemoglobin and iron in the body faster after blood donation, a...                    What Is the Doctor's Reaction? An estimated 38% of people in the United States are eligible to donate blood. But fewer than 10% of them do. That means the American Red Cross relies heavily on the people who donate often. In the United States, you can donate a pint of blood once every 8 weeks as long as your blood hemoglobin level stays at 12.5 grams per deciliter. Hemoglobin is the protein-iron complex in red blood cells. Hemoglobin picks up oxygen from the lungs and releases it into cells as blood moves through the body. To keep hemoglobin levels normal, you need to have enough iron in your body. When you donate a pint of blood, you lose about 230 milligrams of iron. Your small intestine responds to the loss of iron by absorbing more iron from your foods than usual. But it actually takes more than 8 weeks for most people to regain all the iron stores they had before donation. This study looked at whether taking an iron pill daily after donating blood will help your hemoglobin levels rise faster than not taking a pill. The answer is clearly yes. What Changes Can I Make Now? If you donate blood often, you should take an iron supplement. Even if you only donate blood once a year, it probably is worthwhile to take extra iron for two to three months afterward. Mild iron deficiency does not always cause a low hemoglobin level. But you can still have symptoms related to low stores of iron, such as:
  • Fatigue
  • Decreased ability to exercise
  • Problems with concentrating
  • Restless legs
These researchers chose a pill called ferrous gluconate. Iron pills can sometimes cause an upset stomach and constipation. Ferrous gluconate tends to cause these side effects less often than other forms of iron. The standard dose is 325 milligrams of ferrous gluconate. Each pill contains 37.5 milligrams of iron. Iron is best taken on an empty stomach. But if this causes any nausea or stomach upset, it's fine to take your pills with food. But don't take them with milk, antacids or calcium. These do block absorption. Taking the pills with orange juice or 250 milligrams of vitamin C can help the body better absorb the iron. Don't be alarmed if your stool gets very dark, even black. It's from the iron. What Can I Expect Looking to the Future? In the near future, the American Red Cross will likely recommend that blood donors talk with their doctor about taking iron pills.  Given the safety of low-dose iron pills, this should become standard practice for anyone giving blood more than once a year.]]>
Wed, 11 Feb 2015 00:00:00 -0500
Fewer Hearts Accepted for Transplant Transplant centers and surgeons are accepting only 1 in 3 donated hearts for use in patients, a...                    What Is the Doctor's Reaction? Many of my patients have received organ transplants. As a primary care doctor, I see patients before their transplants. They are usually very, very sick with poor quality of life. I am fortunate to see them get a second chance at life after receiving a kidney, bone marrow, a heart, a liver, lungs or other organs. In the United States, medical literature shows that more than 20,000 people could benefit from heart transplants each year. In 2011, fewer than 2,000 transplants were done. Many people die while waiting for donor hearts. Without question, there is a shortage of donor organs. Yet this article points out that, of the hearts that are donated, only about 1 in 3 is accepted for transplantation. This article looks at the reasons transplant programs choose not to use donor hearts. No standard criteria exist for using (or rejecting) a heart.  Researchers used a database of information about all organ donors and people who received transplants. Here's what they found out:
  • Of more than 80,000 potential donor hearts, only 34% were accepted to be used for a transplant. 
  • In 1995, more than 44% of the hearts were accepted. This decreased to 29% in 2006 and then rose to 32% in 2010.  The decline that occurred since the '90s contributed to the increasingly long waiting times for a heart.
  • Hearts that were less likely to be used included those from female donors, older donors and donors with a history of high blood pressure, diabetes or stroke.
  • Some regions refused a greater percentage of donor hearts than other regions. 
Why is the use of donated hearts so low? Why does it vary from place to place? What percentage of donated hearts can be used safely?  The study authors suggest some possible reasons for the numbers. First, as a bridge to transplant, many patients become more stable with mechanical devices to circulate blood. When patients are stable, doctors might be reluctant to transplant a less-than-perfect heart. Refusing hearts increases the waiting time and decreases the number of transplants. The authors also suggest that increased federal oversight also may tend to make doctors more reluctant to accept donor hearts that seem riskier. This also would reduce transplant rates. And it may contribute to the differences among regions. Transplant centers may have different interpretations of what is appropriate.  We don't really know if hearts are being rejected for the right reasons.  During the study period, heart-transplant survival improved by 3%. This suggests that rejecting some hearts might be the right thing to do. Yet many people die while waiting for a heart. So clearly we have to balance these competing needs. This is an important study. It helps us see that more donated hearts are being rejected for transplant, despite the shortage of donor hearts. The study doesn't explain this change. Nor does it explain why rejection rates for donor hearts vary by region. But it does point out the need for more research and clear criteria about which donated hearts are best for the many, many waiting patients. What Changes Can I Make Now? I hope that you will never, ever need a heart transplant. But if you are waiting for a transplant, you and your family might try to learn more about how your transplant program chooses suitable donor hearts. Ask your doctor about this and learn as much as you can. Many more of us are in the position to be organ donors. More than 100,000 people are waiting for donated organs and tissues. Do you have questions about what it means to be an organ donor? You can find good answers at this government website. If you feel certain that you want to be an organ donor, you can take some steps to ensure that it happens.
  • Sign up.
  • Designate yourself as a donor on your driver's license.
  • Tell your family, friends, doctor or clergy that you are an organ donor.
  • Include your desire to be an organ donor in your advanced directives, will or living will.
What Can I Expect Looking to the Future? This article shows the compelling need for evidence-based standards regarding the use of donated hearts. It is also clear that we need more research to find out which hearts will provide the best results for the many people who need them.]]>
Tue, 10 Feb 2015 13:54:00 -0500
Study Finds No STI Boost after HPV Vaccine Getting a vaccine to prevent human papillomavirus (HPV) does not make teenage girls more likely to...                    What Is the Doctor's Reaction? The vaccine against human papilloma virus, or HPV, is very effective.  This is great news, as HPV is the leading cause of cervical cancer. It is also responsible for genital warts, as well as some types of cancer of the penis and anus in men. You'd think that most parents would want this vaccine. After all, who wouldn't want to prevent cancer in their child? It turns out, though, that many parents don't want this vaccine. In 2013, only about half of teen girls had one or two of the three recommended doses. Just over one-third had all three doses. There are many possible reasons for this. But one of the main reasons, researchers believe, is that HPV is a sexually transmitted infection (STI) -- and this makes parents uncomfortable. They think that giving a vaccine that protects against an STI gives tacit permission to their children to have sex. And they worry that the vaccine may make teenagers think that they won't get any STIs at all if they have sex. So many parents refuse the vaccine. Various researchers have looked to see whether getting the HPV vaccine makes teens more likely to have sex, or to take risks with having sex (such as not using birth control). So far, all the research suggests that this isn't the case. Researchers from Boston decided to look at these questions yet another way. Using insurance information, they looked to see if teen girls who had received the HPV vaccine were more likely to get STIs (presumably from risky sexual behavior) than those who hadn't had the vaccine. They found was that girls who got the vaccine were more likely to have STIs -- but that this was true before they got the vaccine, too. Getting the vaccine didn't change anything. It didn't make them more likely to get STIs. What Changes Can I Make Now? If you have a teen, or a preteen, please talk to your child's doctor about the HPV vaccine. It's given in three doses, starting as young as 9 years old. In fact, starting younger may be the best bet. This will help make  sure that all three doses are given before your child starts having sex. (By the end of high school, two-thirds of teens have had sex, and many start much earlier.) If you wait to start the vaccine, your youth may not even get all three doses. (As youth get older, they tend to go to the doctor less.) We've been giving this vaccine for many years now, and feel very comfortable with its safety.  It's important to think about this vaccine as a vaccine against cancer. Yes, the virus it prevents is caught by having sex. But it's a virus that causes cancer -- and that's the kind of virus that all parents should want to prevent in their child. Making safe and healthy choices about sex isn't determined by whether or not you get a vaccine. The best way to be sure that your children make safe and healthy choices is to talk with them. Help them to have the information, self-esteem and strategies they need to make good decisions. While all of this makes many parents uncomfortable, it's incredibly important. What Can I Expect Looking to the Future? I hope that this study and others like it will help reassure parents that the HPV vaccine is a good idea. If we can do that, and get more youth vaccinated, we can protect them against the cancers caused by HPV -- and save lives.]]> Mon, 09 Feb 2015 00:00:00 -0500 Study: Fast Blood-Pressure Treatment Matters Treating high blood pressure quickly can make a big difference in people's future health, a new...                    What Is the Doctor's Reaction? High blood pressure is the major factor that increases the risk of developing heart disease and having a stroke. Everyone knows that. But many people don't actually believe that this applies to them. They are reluctant to take action to lower their blood pressure and keep it in the normal range. I have seen this with many patients who have high blood pressure readings in my office. Often they will say, "Give me some time to work on my diet and exercise. I'll get that blood pressure down." It rarely works. The results of this study remind us of the dangers of waiting too long to:
  • Start treatment when high blood pressure is diagnosed
  • Add a new medicine or increase your medicine dose when blood pressure remains high
 The study offers evidence to support answers to these three questions:
  1. How long after a high blood pressure reading is found should I start treatment or begin more intense treatment? Within 6 weeks.
  2. What level of systolic blood pressure (the top number in a blood pressure reading) indicates that I need more medicine? 150 or higher (but your personal target may be lower than 140).
  3. How soon should blood pressure be rechecked after a change in medicines? No longer than 2 to 3 months later.
If your blood pressure is very high, your doctor will likely do another check much sooner after starting a medicine or adding more medicine. You might need a recheck in five to seven days to be sure blood pressure is heading down without causing a huge drop. In general, you can see the maximum effects of the medicine change in about four weeks. So doctors commonly arrange to take a repeat blood pressure reading in four to six weeks. What Changes Can I Make Now? If you have high blood pressure, a home blood pressure monitor is a great investment. Instead of needing office visits, you can call your doctor's office to report your readings. You likely will save the money you spent on your blood pressure monitor within 6 to 12 months by avoiding travel costs and insurance copays. Buy an electronic device that gives you a digital readout of your blood pressure. If you can, get an arm cuff. The wrist and finger models are less accurate. Make sure it fits properly. The right-size cuff should cover 80% of the upper half of your arm. Some blood pressure devices are designed to cover the lower half. The same 80% rule applies. The cost is between $40 and $100. You can buy the devices at drugstores and medical specialty shops, as well as through catalogs and on the Internet. When you first start to check your blood pressure at home, do it twice a day for a week. Measure it early in the morning, shortly after you wake up, and again in the evening. If you take blood pressure pills, check your pressure just before you take them. Follow these steps each time you take a reading:
  • During the 30 minutes before the test, avoid drinks containing caffeine or alcohol, and don't smoke.
  • Before taking your blood pressure, sit quietly for 5 minutes with your back supported and feet on the floor.
  • When making the measurement, support your arm so your elbow is at the level of your heart.
  • Push your sleeve out of the way and wrap the cuff over bare skin. Measure your blood pressure according to the machine's instructions.
  • Leave the deflated cuff in place, wait a minute, then take a second reading. If the readings are close, average them. If not, repeat again and average the 3 readings.
  • Don't panic if a reading is high. Relax for a few minutes and try again.
  • Keep a record of your blood pressure readings and the time of day they are made.
Take your new monitor with you the next time your visit your doctor's office, along with the record of your readings. The nurse or doctor can check to make sure your machine is accurate and you are doing it right. What Can I Expect Looking to the Future? Doctors commonly give action plans to people with asthma. The plans allow them to make changes in treatment based on symptoms and home air-flow measurements. A similar model can be used for people with high blood pressure.]]>
Fri, 06 Feb 2015 00:00:00 -0500
New Stroke Treatment Fast, but Not Effective It's possible for people who are having a stroke to get early drug treatment on the way to the...                    What Is the Doctor's Reaction? When someone is having a stroke, every minute counts. Strokes are caused by an interruption in blood flow to the brain. This leads to brain injury.  If blood is cut off for just a few minutes, brain damage is usually permanent. The goals of treatment include prompt restoration of blood flow and protection of brain tissue.  Yet it's challenging to treat stroke victims quickly. By the time a person with symptoms of stroke arrives at the emergency room, it's often too late to save the brain from major damage. For decades, doctors and first responders have been working to reduce the amount of time it takes to start treatment. A new study shows how far we've come. The New England Journal of Medicine published the study. Researchers describe a study of 1,700 people with symptoms of stroke. Paramedics evaluated them and then called a neurologist to confirm that each person was eligible for the study.  After getting permission from the patient or a representative, the paramedics gave intravenous magnesium sulfate or a placebo. Magnesium sulfate was chosen because in animal studies it seemed to protect the brain from stroke-related damage. Here's what the researchers learned:
  • Their program was able to deliver medicine quickly.
    • Nearly three-quarters of those in the study received treatment within an hour of when symptoms began.
    • The time between calling 911 and receiving treatment was about 30 minutes.
Unfortunately, those receiving magnesium sulfate were no better off than those receiving a placebo. After 90 days, both groups had similar survival rates and function. Although magnesium sulfate was disappointing as a treatment, the importance of this study is that the system researchers set up was able to provide treatment faster than usual. Treatment within an hour is considered ideal. And this was achieved for most people. In most places (and in prior studies), it has been unusual for stroke treatment outside of a hospital to begin this quickly.  When more effective stroke treatments are developed, this study may prove pivotal as an example of how to begin those treatments quickly. What Changes Can I Make Now? Know the factors linked with a higher risk of stroke. These include:
  • Advanced age
  • High blood pressure (hypertension)
  • Smoking
  • Diabetes
  • Heart and blood vessel disease (such as prior heart attack)
  • Family history of stroke
  • High cholesterol
  • Atrial fibrillation (an abnormal heart rhythm)
You can take steps to reduce your risk factors for stroke.
  • Quit smoking.
  • If you have any of the medical conditions above:
    • See your doctor regularly.
    • Adjust your diet, as recommended by your doctor or a nutritionist.
    • Take your medicines as prescribed.
    • Lose excess weight.
    • Exercise regularly.
Recognize the common symptoms of stroke, including:
  • Sudden dizziness or confusion
  • Weakness on one side of the body
  • Clumsiness or problems with walking normally
  • Sudden loss of the ability to speak or understand speech
  • Loss of vision
  • Facial drooping on one side or slurred speech
Have a plan to get care quickly in the event of a stroke, especially if you have risk factors for the disease. Carry your medical and emergency contact information with you. Know where the closest hospital is. If you have a stroke, the sooner you can get to a hospital, the better your chances of recovery. Only a hospital can give the necessary tests and treatment, such as powerful clot-busting medicines. What Can I Expect Looking to the Future? Considering how vulnerable the brain is when injured, we must develop systems to deliver stroke treatment faster. This study proves it can be done. But rapid treatment is not enough. Stroke treatment must also be safe and effective. We don't yet have highly effective treatments for stroke that can be given before someone gets to the hospital.  Researchers are working hard to change that.]]>
Thu, 05 Feb 2015 00:00:00 -0500
End-of-Life Pain, Depression May Be Growing Pain, depression and other symptoms may be growing even more common in the last year of life,...                    What Is the Doctor's Reaction? The results of this study are a surprise. Based on my own experience taking care of patients in the hospital, I would have predicted some progress in end-of-life care. Similar to most hospitals, my hospital has a very active palliative-care team. The team consists of doctors, physician assistants and social workers. Members of the team spend a lot of time with patients and families. They work to understand what is needed for physical and mental comfort, especially when death is near. So why do families still give a rather poor rating to end-of-life care? I think the main reasons are:
  • How doctors are trained in hospital care
  • The sense of  "failure" when a patient dies
  • Discomfort with having a frank discussion about a very bad prognosis for the patient
As a medical student, intern and resident, a doctor's most intense training occurs in the hospital. It's very focused on making the right diagnosis and paying attention to details. By details, I mean making sure that a patient's vital signs are stable and closely monitoring the balance of fluids and blood chemicals. This attention to these details is necessary to help patients recover from illness or surgery. But for a patient at the end of life, managing these details will not change the outcome. Instead, it takes away from what the focus should be. That is to relieve pain, ease depression and attempt to lessen fatigue. The medical team could be addressing these end-of-life concerns at the same time. But the patient and family may not perceive this. What they see is the constant monitoring of vital signs, frequent blood draws and perhaps more tests. Too often doctors delay moving a person with no chance of recovery to what is known as "comfort measures only (CMO)." This means that the total focus is on comfort. Only tasks and medicines that provide comfort are still given. Perhaps the lack of improvement that this study found in end-of-life care is directly related to waiting too long to move to CMO status. What Changes Can I Make Now? It starts with finding out the prognosis. You may need to take the lead on this.  Doctors have been trained to maintain life.  We don't want to acknowledge that no treatment will prevent the eventual outcome of death. We tend to delay accepting the real prognosis ourselves and therefore wait too long to tell the patient and family. If the prognosis is indeed very poor, then you should review your priorities with your doctor. Your health-care proxy and family can help guide the answers. Here are some important issues to think about and discuss:
  • What is most important for you at this time?
  • What do you worry about most?
  • Do you wish to be absolutely pain-free, even if it means being less alert and awake?
  • Do you wish to continue intravenous fluids or feedings through a tube if you can no longer safely swallow or cannot drink enough by mouth?
What Can I Expect Looking to the Future? End-of-life care was missing for too long in medical education. That is already changing. However, young doctors see the rapid progress we continue to make in treatments of what used to be terminal diseases. So, when faced with a very ill patient who has little chance of recovery, they still may find it difficult to accept that reality.]]>
Wed, 04 Feb 2015 14:28:00 -0500
Simple Methods Help Prevent Hospital Delirium Delirium is common among older patients in hospitals, but simple methods can help prevent it, a...                    What Is the Doctor's Reaction? Delirium happens often in people ages 65 and over when they spend days in a hospital. It's especially common after surgery or during a stay in an intensive care unit (ICU). There is no magic medicine to treat it. But this report once again emphasizes that we can help prevent it from happening. Delirium is a confused and scrambled state of mind. It usually comes on suddenly. Memory suffers, and thinking becomes disorganized. The person may see or hear things that aren't there (hallucinations). Delirium is easiest to recognize when someone is agitated and restless. But it is often overlooked when a person is quiet but has no idea what is going on. The person may not even realize he or she is in the hospital. There's no way to determine how much a person with delirium suffers. But there's no question about how disturbing it is for family and friends to see the big changes in their loved one. Delirium also:
  • Increases the risk of falls
  • Lengthens hospital stays
  • Makes existing dementia worse
  • Makes it more likely the person will need nursing home care, rather than go home from the hospital
For this report, the researchers reviewed clinical trials that looked at non-drug strategies for delirium prevention. They found 14 studies that met their criteria. Based on their findings, using these strategies can reduce delirium by 50% and fall risk by 60%. Delirium is the factor most likely to increase the risk of hospital falls. What Changes Can I Make Now? Family members and friends can help to prevent delirium. Here are some things you can do:
  • Bring glasses, hearing aids (with fresh batteries) and dentures to the hospital. Older people do better if they can see, hear and eat.
  • Bring in a few familiar objects from home. Family photos, a favorite comforter or blanket for the bed, rosary beads, a beloved book or relaxation tapes can be comforting.
  • Keep easy-to-read clocks and calendars visible. One reason people get disoriented in the hospital is that they can't go by normal cues, such as daylight. Not all beds are near a window, and ICU rooms may not have windows. A few well-placed clocks and calendars can help fill that void.
  • Always speak in a calm and reassuring tone of voice. Talk about personal and current events.
  • Help orient people throughout the day. Use short, simple statements about the date and time.
  • Remind them that they are in the hospital and why they are there. In simple terms, explain what is being done to help them feel better.
  • When giving instructions, state one fact or simple task at a time. More could be overwhelming.
  • Stay with people who are in the hospital as much as possible. If they develop delirium, try to arrange shifts so family or friends can be there around the clock.
  • Ask nurses what can be done to avoid waking people at night. Can vital signs be skipped when sleeping? Can the medicine schedule be changed?
If you detect new signs that could indicate delirium, discuss them with the nurses or doctors as soon as you can. These signs could include confusion, memory problems and personality changes. Family members are often the first to notice subtle changes. If you see any signs of early delirium, ask the nurse or doctor if any medicines might be contributing. What Can I Expect Looking to the Future? Using strategies to prevent delirium make sense. It also might seem straightforward to accomplish. But most patients in the hospital today require frequent monitoring and round-the-clock care. Given this reality, the help of family and friends is more important than ever to prevent delirium.]]>
Tue, 03 Feb 2015 00:00:00 -0500
Survey: Many Skip Drugs Because of Cost About 8% of Americans don't take their medicines as prescribed because they can't afford them, a...                    What Is the Doctor's Reaction? Medicines don't work if you don't take them. Some people don't take their prescription drugs regularly because they forget them. Some are bothered by side effects. This report reminds us of another very important reason. Many people can't pay for them. The researchers used survey data from the 2013 National Health Interview. About 8% of those surveyed said they did not take medicines prescribed by their doctors because they could not afford them. About 20% of prescriptions don't even get filled. The results of a prior survey suggest that the high cost of drugs is the main reason. Many more people may be skipping doses to save money. Given the high price tag, it's not surprising that so many Americans choose not to fill a prescription or take it as directed. Even with health insurance that includes a drug benefit, people might not be able to afford the copayments. New medicines continue to be approved each year. Almost none are taken off the market. The price of new drugs is always high. And only a few get cheaper when they become available as generics. Each year doctors continue to prescribe more drugs than the year before. Today, many people are taking 5 or more different prescription drugs a day. The patients I admit to the hospital often have 10 and sometimes 15 different drugs listed on their medical record. Even if they could afford them, managing that many medicines is a challenge and often impossible. What Changes Can I Make Now? If you are having difficulty affording your medicines, ask your doctor these questions:
  • Which medicines are the most essential for me? Ask the doctor to explain how this drug improves your quality of life, keeps you out of the hospital and/or helps you live longer.
  • Which medicines might I be able to stop with minimal risk to my health? There often are not easy answers to this question. You may need to do your own research to make a shared decision with your doctor.
  • Are there lifestyle changes I can make now that might allow me to stop some of my medicines? For example, you could change your diet or exercise more.If you have high blood pressure or diabetes, such changes can almost always help decrease the number and dose of drugs you take.
More cost-saving tips:
  • If you have a prescription drug plan, ask your doctor to prescribe the drugs that are "preferred" by your insurance company. These will be the least expensive.
  • Go for the generic version if available.
  • If no generic exists, ask your doctor or pharmacist if an alternative brand-name drug that is cheaper would work just as well.
  • Ask your doctor or pharmacist about pill splitting. Usually there is a minimal cost difference between low-dose and high-dose pills of a particular drug. Get the higher dose and split the pill.
  • Shop around. Prices can vary a lot. I recently compared the price of a commonly prescribed antibiotic. I found a drugstore that charged one-third the price found in another store.
What Can I Expect Looking to the Future? Certain new drugs will always be expensive. Recently approved drugs that treat and potentially cure hepatitis C are one example. But for medicines used to treat common conditions -- such as diabetes, high blood pressure and heart disease -- prices can come down. If all of us take the steps outlined above, drug companies will need to respond. Doctors will prescribe fewer of the most expensive medicines. To keep market share, drug costs should come down.]]>
Fri, 30 Jan 2015 13:20:00 -0500
Study: Effect Stronger for 'Expensive' Placebo A small new study of people with Parkinson's disease underscores the power of what's known as the...                    What Is the Doctor's Reaction? Do you believe that that you have to pay more to get good quality?  Do you think that applies to medicines as well? A fascinating new study suggests that if you think a drug costs more it will be more effective! The small study was just published in the medical journal Neurology. Researchers enrolled 12 people with Parkinson's disease. This is a condition that causes tremors and difficulty with movement. In some cases, it can lead to dementia and death. It's thought to be caused by reduced production of dopamine. This chemical is essential for carrying messages in certain parts of the brain. In the study, people were told they'd get an injection of an expensive drug or a lower-cost version of the same drug. They were told that the expensive version cost $1,500 per dose. The low-cost version cost $100 per dose. In fact, they were getting a placebo (of saline) every time. Tests of motor skills and brain scans were performed before and after the injections. The researchers found that:
  • On average, people improved, regardless of which injection they received.
  • When people thought they were receiving an expensive treatment, they improved much more than when they thought the treatment cost less.  For some measures, the improvement was doubled for the "expensive" treatment compared with the "cheap" one.
  • Brain scan results of those taking the "expensive" treatment looked a bit like scans of people taking levodopa, a proven drug for Parkinson's disease. The same was not true for the less costly treatment.
  • When people were interviewed later, they were told that the injections were actually placebos. It appeared that what they had expected affected their response to the injections. Eight people said they had expected the more costly drug to work better. They did, in fact, improve the most.
Meanwhile, the rest said they had not expected more benefit from one drug over the other. They did not improve as much. For most of the people involved in this study, being told that a drug was quite expensive led them to expect it would work better than a cheaper version. Apparently, this somehow "tricked" the brain into improved function. Previous research has already shown that a placebo can increase the brain's production of dopamine. This study shows that the perceived cost can play a role in increasing the placebo effect. This study also raises an ethical question: was it acceptable for the researchers to deceive people who took part in this study? An independent review board found that the study design did not pose significant risks to study subjects or violate their rights. The board found that it also followed federal research rules. Still, it's not common to inject people in a study with a placebo without at least letting them know that they might get a placebo. What Changes Can I Make Now? Study after study -- including the research described here -- has shown how placebo treatments can lead to improvement. Just how placebos work is not clear. But the benefits of placebo treatments shouldn't be ignored. I think it's worth embracing the notion that expecting a benefit can increase the likelihood that a treatment will work. The opposite may also be true. An expectation that a treatment will not work may reduce the chances it will help. And expecting that a medicine will cause side effects may increase the likelihood that it will. This is sometimes called the "nocebo effect." So the next time your doctor recommends a treatment, ask about its potential risks and benefits, but:
  • Keep an open mind -- and a positive attitude -- about its potential to help
  • Try not to focus solely on risks. All medicines come with risk. But there is also risk in not being treated. For example, without treatment you may have increased symptoms, or your condition may get worse.
  • When asking about side effects, find out how likely they are. The chance of your having a serious side effect may be so low that it should not weigh heavily on your decision to accept a treatment.
Consider enrolling in a clinical trial. You'll be advancing medical science, helping doctors figure out which treatments are safest and work best. You also may get access to an effective treatment that would not be available otherwise. But ask if it's possible that you'll be treated with a placebo. What Can I Expect Looking to the Future? In the future, I think we will have a better understanding of how the placebo effect works and how to use it to enhance health. I also hope that we will discover the cause of common chronic diseases, such as Parkinson's disease, so that we can find ways to prevent them. After all, no matter how big the placebo effect, it will always be better to prevent the disease is the first place.]]>
Thu, 29 Jan 2015 14:01:00 -0500
Study: High Cholesterol in Middle Age Risky Having high cholesterol for a long time, even in your 30s and 40s, can increase your risk of heart...                    What Is the Doctor's Reaction? For years, doctors prescribed drugs to lower cholesterol based largely on blood test results. For most people, an LDL ("bad cholesterol") level of 130 milligrams per deciliter of blood (mg/dL) was enough to trigger concern. The goal was lower for people with heart disease or diabetes. The drugs prescribed were usually statins. But recent guidelines on statin use proposed a major change to that strategy. The American Heart Association and the American College of Cardiology issued the guidelines in 2013. The new guidelines take away this "target-driven" approach. They don't focus on the LDL numbers. Instead, they recommend using risk to decide when people should take a statin to lower LDL. High risk means a greater than 7.5% chance of having a heart attack or stroke within 10 years. Risk is largely determined by age. The results of this study suggest we should not completely ignore the LDL cholesterol number. Even slightly high levels over many years in early adulthood increase the risk of heart disease, including heart attack. Specifically, these researchers looked at younger adults who had moderately high LDL (130 mg/dL) for 15 years. Their risk of developing heart disease was 4 times as high as the risk for those who always had normal LDL levels. A moderately high LDL level usually would not require drug treatment. The exceptions would be for people who had diabetes or multiple other factors that increase the risk of coronary artery disease. The study was not designed to look at whether younger adults who have only a moderately high LDL level should consider taking a statin. What Changes Can I Make Now? No matter how young you are, you should be taking a statin if you have:
  • Artery disease, including angina (chest pain with exercise or stress), a previous heart attack or stroke, or other related conditions
  • A very high level of harmful LDL cholesterol (generally at or above 190 mg/dL)
  • Diabetes, if you are also 40 or older
For everyone else under age 50, doctors will focus on the risk score. Diet and exercise will always be the first approach for those with moderately high LDL and a risk score under 7.5%. Whether to take a statin would be a decision that you make with your doctor. It depends on how many factors you have that increase your risk. Risk factors include:
  • A parent, brother or sister who had coronary artery disease or stroke at an early age (a man before age 55 or a woman before age 65)
  • Tobacco use
  • High blood pressure
  • A low HDL ("good cholesterol") level (under 40 milligrams per deciliter)
If you do start a statin, the goals have changed. You don't need to lower your LDL level to a specific number. Instead, you start at a low dose and work up to a certain "intensity" of statin treatment:
  • Moderate-intensity treatment lowers LDL by 30% to 50%.
  • High-intensity treatment lowers LDL by 50% or more.
What Can I Expect Looking to the Future? The new guidelines provide a better approach to treatment of high cholesterol. Similar to all guidelines, this one should not dictate what is best for any specific person. For many older people with a risk score greater than 7.5%, a statin likely would cause more harm than benefit. And many younger people with a score under 7.5% should take a statin.]]>
Wed, 28 Jan 2015 14:01:00 -0500
Extra Tests May Not Help for Chest Pain People who go to a hospital with chest pain, but are not having heart attacks, may not be helped... were more likely than others to have procedures to open up narrowed arteries near the heart. But this didn't reduce their chances of having a heart attack during the study period. The journal JAMA Internal Medicine published the study. HealthDay News wrote about it January 26.                    What Is the Doctor's Reaction? Chest pain is one of the most common reasons people go to the emergency room. That's understandable. If you have chest pain, it can mean that you have blockages in the arteries near your heart. You may be having a heart attack, or you may be at high risk for one. Fortunately, most of the time people with chest pain are not having a heart attack. Most emergency rooms have a standard way to rule out a heart attack.  Commonly, people get an electrocardiogram (ECG) and blood tests. If either of those tests shows evidence of heart damage, then the patient will have urgent further treatment. When those tests don't suggest a heart attack, it is common to do another test to assess the person's risk of having a heart attack days, weeks or months down the line.  Some of these low-risk patients may have an exercise test. They will walk on a treadmill to see if exercise reveals any evidence of a heart blockage. Other patients might have an echocardiogram or a test that uses a radioactive substance. Some may have a special kind of CT scan.  Some may have no testing at all. The goal of this study was to see whether future heart attacks were less likely to occur with one of the testing strategies. Researchers also wanted to see which tests for these low-risk patients were most likely to lead to more invasive heart tests or procedures. The authors studied the insurance records for more than 690,000 privately insured patients. All of them had an emergency room diagnosis of chest pain. The researchers excluded anyone who had a heart attack or a procedure to open blocked arteries within 24 hours after coming to the emergency room. They also excluded some other very common causes of chest pain that are not caused by blocked arteries. These included pneumonia, inflammation of the sac around the heart, and heart failure. Then the researchers looked at what happened to the other patients whose tests showed they were not having heart attacks. One group had further tests, and the other group did not. What the study found was very interesting:
  • After a week, only 11 of every 10,000 in either group ended up back in the hospital for a heart attack.
  • After 6 months, only 33 of every 10,000 in either group had evidence of a heart attack.
  • Whether these low-risk patients had follow-up testing or not, they had a low likelihood of heart attack within the next 6 months.
  • People who did have follow-up testing were more likely to get a cardiac catheterization, a type of X-ray that looks at the inside of the arteries around the heart. This test may have exposed them to increased radiation and risk that might not have been warranted.
It's important to understand a few things about the group that was studied. In general, they were at low risk for a heart attack. They didn't have any chemical or electrical evidence of heart attack, and they were relatively young. This study used a commercial insurance population. In this way, researchers excluded most Medicare patients. These patients are generally either over 65 or unable to work, often due to many medical conditions.   The authors state an important tenet in medicine: "When the risk of an event is low, it is difficult to reduce it further."  This study is an excellent beginning to help us think about the best course of treatment in the emergency room and soon afterward for people who are at very low risk of future heart attacks. It will help us use limited resources wisely and reduce the risk of problems caused by tests that people don’t need. What Changes Can I Make Now? Chest pain is a common symptom. We all worry that it could be a heart attack. The American Heart Association has a beautiful list describing the warning signs of a heart attack. Here are some of the most common ones:
  • Chest discomfort that can feel like squeezing or pressure and might get worse with exercise
  • Neck, jaw or stomach discomfort
  • Shortness of breath
  • Nausea
  • Heavy sweating
These are the classic symptoms. Some people might have less typical symptoms, particularly women and people with diabetes. Talk to your doctor about warning signs of heart attack. If you go to the emergency room with chest pain, you can expect a thorough evaluation. This will include an electrocardiogram, blood tests, and, if indicated, further studies. This new study will help your doctor decide with more accuracy what's best for you. What Can I Expect Looking to the Future? This is a fascinating look at how to predict future heart-attack risk for someone with chest pain but no heart attack. I would love to see a study that randomly assigned patients like these to receive or not receive follow-up testing in the emergency room. A study like this could help to show if no further testing was safe and effective for patients who were generally young, healthy and at very low risk of a heart attack.]]>
Tue, 27 Jan 2015 14:14:00 -0500
Measles Cases Linked to Disneyland Rise to 78 At least 78 cases of measles have now been reported in an outbreak traced to Disneyland, public...                    What Is the Doctor's Reaction? An outbreak of measles in the United States has been linked to Disneyland in California.  According to the Centers for Disease Control and Prevention (CDC), 68 measles cases have already been identified in just the first few weeks of 2015. Measles is a very serious disease. It can cause:
  • Blindness
  • Brain infection (encephalitis)
  • Serious diarrhea
  • Ear infections
  • Lung infections (pneumonia)
Babies less than 12 months of age are at highest risk of having serious illness, needing care in the hospital, and even dying.  The World Health Organization (WHO) estimates there were about 122,000 deaths from measles worldwide in 2012. Very few cases of measles used to occur in the United States, thanks to the measles-mumps-rubella (MMR) vaccine. But things have changed during the last 10 to 15 years.
  • Not all children are getting the MMR vaccine. Others get it much later than recommended. This means they are not protected from measles when they should be.
  • Americans often travel all over the world. Others come here from lots of different countries. This puts more people at risk of being exposed to measles both here and abroad.
The measles virus spreads easily and quickly. Someone infected with measles has a fever, cough, runny nose and pink eye. Then comes the rash, which spreads head to toe. The virus can be in droplets or in the air after a cough or sneeze. It can live on surfaces for up to 2 hours. The CDC points out that you do not need to be close to where this outbreak started to be at risk for measles. Anyone who has come back from traveling here or abroad can be infected. The best way to prevent measles is to get the MMR vaccine. Of the people who got measles in California, 34 reported whether or not they had received the vaccine. About 82% had not been vaccinated. What Changes Can I Make Now? Get your child vaccinated with the MMR vaccine on time to offer the best protection. The MMR vaccine is very safe. It is more than 95% effective. Vaccination also will help stop the spread of measles, mumps and rubella in the community, especially to babies who are too young to get the shots.  The CDC, American Academy of Pediatrics and American Academy of Family Physicians all recommend that children get 2 doses of MMR vaccine:
  • First dose at 12 to 15 months of age
  • Second dose at 4 to 6 years of age
Children who travel outside of the United States also should be up to date with their MMR vaccines.
  • Infants 6 to 11 months old need 1 dose of MMR vaccine before they leave the United States. This dose does not count toward the 2 recommended doses everyone needs.
  • Children 12 months and older should get 2 doses before traveling. The first dose is given on or after age 12 months. The second dose should be given at least 4 weeks later.
Vaccines have saved countless children from illness and death.
  • Vaccines work! The number of infections from vaccine-preventable diseases has gone down by more than 90%.
  • Vaccine-preventable diseases are still common in many parts of the world. Children who do not get vaccines could easily get one of these diseases while traveling or from a traveler to the United States.
  • Not following vaccine advice puts your child's health in danger.  The diseases that vaccines prevent can result in serious illness.
  • Vaccination means fewer days missed from work and school. Time lost from work to care for a child with a vaccine-preventable disease can be costly for the family.
  • Vaccination protects your family, friends and community. This is especially important for protecting those who cannot get the vaccines themselves (for example, if they are too young or have immune problems).
  • Vaccines are safe! Before a vaccine is approved and given to children, it is tested a lot. Serious side effects are very rare. The benefits far outweigh the risks.
It also is important not to skip or delay any recommended vaccines. This will leave your child not properly protected for longer periods of time. If a child misses one or more shots, it is not too late to get caught up. Make sure to ask your doctor any questions you may have about vaccines at your child's next checkup. You can also find reliable information about the measles and all vaccinations in the following sources:
  • CDC Measles Web Page
  • CDC Vaccine Information Statements
  • CDC for Parents: Vaccines for Your Children
  • AAP Childhood Immunization Support Program
What Can I Expect Looking to the Future? More families will make sure that their children get the MMR doses at recommended ages. I hope that families also will remember to vaccinate babies before they travel outside the Unites States.  This should lead to fewer cases of measles, mumps and rubella each year. Everyone must work harder to make sure that all children (and adults) are fully vaccinated. Otherwise, more outbreaks of serious diseases, like measles, will be reported in the future.]]>
Mon, 26 Jan 2015 14:22:00 -0500