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 Tue, 22 Jul 2014 14:28:00 -0400 No Heart-Attack Drop for Younger Adults Though heart attacks have declined among older adults, a new study finds that rates have stayed... What Is the Doctor's Reaction? Hospital stays and deaths resulting from heart attacks have declined dramatically for older people. But for adults under the age of 55, the decrease is much less impressive. During the last 10 years, doctors have become more aware of the differences in coronary artery disease between men and women. This is important because most of the studies done to help determine the best way to diagnose heart attacks and other heart problems were done on men. The lessons learned were applied to women. At the time, doctors thought that the symptoms and outcomes would be very similar. They clearly are not. In fact, the differences are quite striking. Many women do not have the classic squeezing chest pain of heart attack. Instead, they might have extreme fatigue, profuse sweating, shortness of breath or all of these. And women of all ages have a greater risk of dying from a heart attack than men. This particular study was designed to look at trends in hospital stays and deaths from heart attacks in men and women younger than 55. For men, there was little change during the 10 years covered by the study. Younger women were just as likely to have a hospital stay after a heart attack in 2010 as in 2001. But there were fewer deaths. Even with the decrease, women's risk of dying in the hospital from a heart attack was consistently higher than the risk for men. The authors did not look at why heart attacks rates and deaths were not falling as much for younger adults as for older ones. Perhaps it is related to less active lifestyles and rising rates of obesity and diabetes. What Changes Can I Make Now? Heart and blood vessel diseases still cause the most deaths in the United States and most developed countries. Prevention must start early in life. The symptoms and outcomes for women with heart disease may be different than those for men. But the way to prevent a heart attack is similar for both sexes.
  • Don't smoke. Quitting reduces your heart attack risk within weeks.
  • Stick to a heart-healthy diet, such as a Mediterranean-style diet.
  • Stay physically active and exercise regularly.
  • Maintain a healthy weight.
  • Keep your blood pressure under control.
  • Work to keep your LDL cholesterol and triglyceride levels down and HDL cholesterol up. Start with diet changes and increased exercise. Add medicines prescribed by your doctor if needed.
What Can I Expect Looking to the Future? Most people know what to do to help prevent heart disease. But far too few are actually doing it. What we need most are new ways to motivate people to reduce heart disease risk and the research to prove that those ways are effective.]]>
Tue, 22 Jul 2014 14:28:00 -0400
Deaths Drop Sharply in HIV Population People infected with HIV in wealthier countries are 28% less likely to die early than they... What Is the Doctor's Reaction? Advances in treatments have made HIV into a different disease than it was in the early years. In the 1990s, the life expectancy for a person with HIV was about 10 years. Now HIV infection doesn't reduce your life expectancy, if you get recommended treatment and you take your medicine reliably. I vividly remember a conversation with a patient from almost 20 years ago. I was having an office visit with a man who had HIV. When he was diagnosed, there was no treatment for HIV or its more advanced stage, AIDS. He watched his close friends die with AIDS. Then he resolved to live well in what he expected to be his final days. What I remember from our conversation was his desperate life planning. "HIV was my death sentence," he said. "Death was a certainty for me. I quit my good job, and I spent my careful savings. I don't have children to leave my money to. Because I knew I would die from HIV, I traveled and splurged, and have done things that I have always wanted to do. I have given away my prized possessions. I timed my spending so that my life savings would run out right now -- but doctor, I am supposed to be dying!" We looked at each other knowingly. A few months before, I had put him on treatment with a drug that was new for HIV back then, AZT. It was a game changer. People were no longer dying quite so "reliably" from HIV. On AZT, my patient's infection was improving beautifully. The idea that he might live for years -- even decades, or perhaps a normal life span -- was startling for both of us. "So what do I do now, doctor?" he asked me. "I have to start over. How can I do that when I spent everything and I don't have a job?" Some years later I lost track of this patient. As treatments improved, my patient and many others became people living with HIV, instead of people dying with HIV. Doctors now think of HIV as a chronic illness, not a "death sentence," as my patient called it. To punctuate the changes in HIV, this week we have updated information about the causes of death for HIV-positive adults. It applies to high-income countries, where treatment is broadly available. The study included almost 50,000 patients with HIV. It found that cancers unrelated to HIV, liver disease and heart disease are now the leading causes of death in HIV patients. Only 29% of HIV-positive adults appear to be dying of AIDS-related causes. For those of us who have cared for HIV patients across several different decades, this is an astonishing statistic. Another article, published in December in the journal PLoS One, estimated these life expectancies for HIV in the United States and Canada:
  • A young adult appropriately taking combination antiviral treatment for HIV would be expected to live into the early 70s (essentially, a normal life span)
  • Some people with HIV don't take their medicines. So average life expectancy for people with HIV overall is lower, in the early 60s.
  • For a young adult injection drug user with HIV, average life expectancy is slightly less than 50 years old.
What Changes Can I Make Now?
If you have HIV, taking medicine to suppress the virus is highly effective, long-term treatment. Most people who die from HIV-linked infections now are people who do not take medicines to treat it. If you have HIV, make a plan with your doctor about appropriate treatment. For most people with HIV, it is helpful to be seen by a specialist in HIV care. This type of doctor is familiar with HIV medicines and will be able to monitor your virus for signs of resistance to drugs. Since treatment is so effective, knowing who has HIV infection is really important. Many people infected with HIV don't know it. Some experts estimate that about 17% of those with HIV do not know that they have the infection. But at least one study (in Boston) estimated that the number was closer to 25%. It is recommended that everyone get tested for HIV once. This way we can find some of these hidden HIV infections. What Can I Expect Looking to the Future? We are still not able to cure HIV. Research is focused on work to produce a vaccine, and methods that might someday completely cure the virus. Even stem cell transplants are being explored. For now, it is wonderful to be able to offer patients treatment for HIV that makes it a less threatening disease.]]>
Fri, 18 Jul 2014 13:17:00 -0400
Potassium May Cut Death Rates with Diuretics Giving extra potassium to everyone taking "water pills" might help people with heart... What Is the Doctor's Reaction? Doctors most often prescribe a type of water pill called a loop diuretic for people who retain a lot of water. Usually the reason is heart failure. Examples of loop diuretics are furosemide (Lasix) and torsemide (Demadex). Loop diuretics cause the kidneys to make more urine. But they also cause the kidneys to lose potassium along with the extra urine. Some people lose (excrete) very little potassium in response to loop diuretics. Other people lose a lot of potassium. This study suggests that for both groups it may be a good idea to take a little extra potassium with a new loop diuretic, starting on day one. Today, when doctors first start a loop diuretic, they usually have the person get a blood check for potassium a few days later. If the potassium is low, the doctor will prescribe a potassium supplement. Fewer doctors routinely prescribe potassium pills when they start patients on loop diuretics. Both strategies are accepted as good practice. However, this new study suggests that starting potassium at the same time as the loop diuretic is linked with longer life than waiting until the potassium is low. This type of research is called an observational study. It only shows that people who started potassium at the same time as a loop diuretic tended to live longer than those who started the diuretic alone.  It does not prove that starting potassium right away actually saved lives. What Changes Can I Make Now? Most Americans don't get nearly enough potassium in their diets. We average 2,500 milligrams a day. That's only about half of the 4,700 milligram minimum recommended for adults. So it makes sense that if you take a loop diuretic you would likely need more potassium. What's surprising is the small amount of extra potassium per day that made a difference in this study. It was 400 milligrams of potassium or less. People prescribed a greater amount of potassium did not have a survival benefit. If you are starting or already taking a loop diuretic, don't just start taking extra potassium. Get advice from your doctor about taking potassium pills  or eating more potassium-rich foods. There are reasons to be cautious about taking extra potassium. It can be dangerous if your kidneys don't function normally or if you take certain medicines. The drugs often used to treat heart failure cause the body to retain potassium. They include:
  • The potassium-sparing diuretics spironolactone (Aldactone) and eplerenone (Inspra)
  • Angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril and many others
  • Angiotensin receptor blockers, such as losartan, valsartan and many others
What Can I Expect Looking to the Future? The results of this study won't change current practice right away for most doctors. But more studies will be done to confirm the findings. It would be terrific if taking a small amount of extra potassium when starting a loop diuretic does indeed improve outcomes.]]>
Thu, 17 Jul 2014 14:11:00 -0400
'Telecare' May Improve Pain Management An automated program to monitor symptoms may improve pain treatment more than typical care, a... What Is the Doctor's Reaction? As unpleasant as pain may be, it usually serves a useful purpose: it warns you of danger. If you touch a hot stove or sprain your ankle, the pain tells you to move your hand away from the stove or to rest your ankle. For this sudden type of pain, the discomfort subsides once the problem has passed or is treated.   But, for millions of people, pain is long lasting (chronic). Examples include back pain, headaches and arthritis pain. In these cases, chronic pain serves no useful purpose. Unfortunately, chronic pain often has an unknown cause and is difficult to cure. That's why doctors often resort to trial and error,  trying one treatment (or combination of treatments) after another.  A new study takes a fresh approach to treating chronic pain. The Journal of the American Medical Association published the study. Researchers enrolled 250 people with chronic pain. Most had had poorly controlled pain for many years. They were randomly assigned to two groups. One group received "telecare." They got automated, symptom-based advice by telephone or Internet according to a standard algorithm. A nurse and doctor supervised the program. The other group received "usual care" from their primary care doctors. Those assigned to receive telecare had:
  • Better pain control -- After one year, about half reported a 30% reduction in pain. This was nearly double the rate of the usual-care group.
  • A lower rate of worsening pain -- After 6 months, only 19% reported worsening of pain. This was about half the rate of those in the usual-care group.
  • Better overall pain treatment -- Almost three-quarters reported good-to-excellent pain control, compared with half of those in the usual-care group.
Another finding deserves particular attention: few people in either group were started on opiates (narcotics). These are the most powerful -- and most commonly abused -- pain medicines.  These findings suggest that automated telephone or Internet-based communication can guide pain treatment effectively. In fact, it may be better than the standard ways doctors treat pain during office visits. Chronic pain is among the most common and vexing problems for which patients see doctors. This study could be among the first to signal a major change in how pain is managed. It could be particularly important for people who have difficulty getting to their doctors' offices and for places with few doctors. What Changes Can I Make Now? If you have unexplained pain, the first step is to see your doctor. If a specific cause can be found, a specific treatment (such as a medicine or surgery) may cure the condition. But, even when there's no cure, some simple steps may help you get more comfortable. For example:
  • Stretching or a heating pad can be an effective treatment for back pain. This works especially well for pain caused by muscle strain or spasm.
  • A wrist brace can lessen pain from tendon inflammation (tendonitis).
  • A change in your exercise routine can make a big difference.  A physical therapist or personal trainer can provide guidance.
There are many other options for treating chronic pain, including:
  • Relaxation exercises
  • Electrical stimulation (using a transcutaneous electrical nerve stimulator, or TENS)
  • Acupuncture
  • Chiropractic care
  • Application of cold (especially just after exercise)
New medicines and a better understanding of how to use them have provided pain sufferers with more options than ever before. Your doctor may recommend one or more of these medicines:
  • Over-the-counter pain relievers (such as acetaminophen)
  • Pain relievers applied to the skin (such as BenGay or capsaicin)
  • Anti-inflammatory drugs (such as ibuprofen)
  • Muscle relaxants (such as cyclobenzaprine)
  • Antidepressants (such as duloxetine)
  • Anticonvulsants (such as gabapentin)
  • Narcotic-like pain relievers (such as tramadol)
  • Narcotics (such as codeine)
Pain can also be treated with injected medicines. Nerve blocks and corticosteroid injections are examples.  All drugs can cause side effects, so be sure you know what to watch out for. Report potential side effects to your doctor. If you take a medicine for pain, take the lowest effective dose. The lower the dose, the fewer and less severe the side effects. If your pain varies in a predictable pattern, it's often better to "stay ahead" of chronic pain. To do this, you would take your medicine at regular times, rather than waiting until you can't bear the pain. As this new research shows, a well-designed protocol that adjusts the choice and dose of medicines based on symptoms can help reduce even pain that has been present for years. What Can I Expect Looking to the Future? It's not always possible to stop pain. However, researchers are busy developing new treatments and, as in this new research, new ways of adjusting them.  Pain is likely to remain a common reason that people seek evaluation and treatment from their doctors. But I hope that in the future we'll see less chronic pain and better pain control.  Advice delivered by phone or the Internet could play a major role.]]>
Wed, 16 Jul 2014 14:31:00 -0400
People Quit More Often if Pills Look Different People may be more likely to stop taking generic drugs if the color or shape changes, a new study... What Is the Doctor's Reaction? People are creatures of habit. When a pill I take daily changed from being a blue circle to a green oval, I asked my pharmacist if there had been a mistake. Often, when I talk to my patients about their medicines, they describe the pills by the shape and color, rather than the brand or generic name. "You know," they'll say.  "I take the little, round white one."  This study looked at what people do when pills change color and shape. It turns out that if you change what people's pills look like, many of them stop taking the medicine. The study was done by several researchers at my own institution. The lead author and I are part of the same large academic practice. The study patients came not from the practice but from a national insurance database. Many previous studies have shown that people who have heart attacks stop taking their new medicines during the first year. This study asked an interesting question: Does a change in the shape or color of a generic drug increase the likelihood that people will quit taking their pills?  The authors looked at three classes of medicine that are critical for patients after a heart attack. They found that nearly one-third of patients had a change in shape or color of at least one pill during the year after their heart attack. The likelihood of stopping a medicine was increased by one-third when a pill changed color and by two-thirds when the pill changed shape! Brand-name pills tend to have a consistent shape and color. When pills become generic, the drug makers are not required to maintain a pill's shape or color, only its ingredients. If more than one company makes generic versions of a particular drug, they could have different shapes and colors. If your pharmacy switches to a different drug maker, your pills may look different. Clearly, the ingredients are the most important things about any medicine. But this study shows that shape and color make a difference -- one that could affect your health.  The results of the study have large implications for public health. If you have a heart attack, it is crucial that you take certain medicines for the long term. If you stop taking these medicines, health problems are more likely to become worse. You may even be more likely to die. This study has some limitations. For example, the authors were not able to see how income or education affected the results. The study also wasn't designed to show if health outcomes were truly worse when people stopped taking their drugs. This is an important study. It should help patients, doctors and policy makers to think carefully about the appearance of medicines and how it affects care. What Changes Can I Make Now? The authors make some excellent suggestions for improving policy related to pill color and shape at the level of the Food and Drug Administration. In the interim, patients, doctors and pharmacists can do much to help themselves. First and foremost: Don't worry about taking generic medicines. They are safe, regulated and an important way to reduce health care costs. People who take generic medicines have the same health outcomes as those who take brand-name drugs. Because they save money, people also may be more likely to stick to their medicine routine.   Yet people commonly change pharmacies, and pharmacies change suppliers. This can lead to changes in the shape or color of a pill that you take. To prevent confusion, here are some tips:
  • Know the names of your medicines. A pill's appearance may change, but the generic name will not! Ask your doctor for a list of your medicines and their doses. Carry it with you in your wallet.
  • If a pill changes shape or color and you're not sure if it is the right pill, find out. It's always OK to ask the pharmacist about any changes. Mistakes are rare, but they do happen, so it's good to be cautious.
  • Even if you use a mail order pharmacy, you should be able to call with questions. 
  • You can always ask your doctor or other provider about changes. 
  • If you plan to stop a medicine, let your doctor know. He or she can work with you to find a safe alternative that doesn't put your health at risk. 
By taking charge of your own medicines, you improve your chances of being a healthier, safer consumer of health care. What Can I Expect Looking to the Future? Studies like these provide guidance for doctors, pharmacists and policy makers to make effective changes for improved public health. I expect that this study will help increase awareness at all levels that the appearance of the pill does, in fact, affect its safety and effectiveness.]]>
Tue, 15 Jul 2014 18:37:00 -0400
Weather Not Linked to Back Pain in Study Does bad weather make your back hurt? Researchers have taken a close look at this question and... What Is the Doctor's Reaction? Sudden low back pain is extremely common. It happens to most of us at least once in a lifetime. But why does this occur? Many people blame changes in the weather. Weather changes are just one of the many opinions about what triggers low back pain and many other types of aches and pains. However, they are just opinions. They are not based on evidence. In fact, very few studies have taken a look at the triggers for low back pain. Daniel Steffens, a Ph.D. student, and his colleagues at the University of Sydney designed an elegant study to better identify what may be real triggers. They recruited 993 patients with acute low back pain. All had been seen in primary care clinics in Sydney, Australia, during a 1-year period.   The researchers used the common definition of acute low back pain:
  • Comes on suddenly, over no more than 24 hours
  • Located between the 12th rib (the lowest rib) and the crease of the buttocks
  • Of at least moderate intensity
  • May or may not occur along with pain that goes into one of the legs
These researchers are studying various triggers for low back pain. The current study looks at the relationship to changes in weather. They could not find any links between low back pain and shifts in air temperature, relative humidity, rain, air pressure or wind direction. There may be some link with high wind speed and wind gusts. What Changes Can I Make Now? Acute low back pain can be extremely painful and frightening. But it almost always will get better with minimal treatment. Often the pain is better in two to three days. But it may take a few weeks. Acute low back pain rarely needs diagnostic testing, such as a CT scan or MRI. But there are situations when the low back pain might be something more serious. For example: 
  • Back pain with fever
  • Back pain in someone who has cancer
  • Back pain that wakes you from sleep (not just waking up and realizing your back still hurts, but pain that wakes you up)
  • Back pain after severe trauma
  • Back pain with loss of control of urine or stool
  • Back pain with weakness in one or both legs
This report suggests that high winds and wind gusts might set off sudden back pain. So it makes sense, if you are prone to having back problems, to be very careful if you do need to go outside under these conditions. Otherwise, don't let weather change what you do. If you do have sudden low back pain, do not remain at bed rest for more than one or two days. When lying down, find whatever position is comfortable to help relieve the pain. Personally, I like to lie flat on my back with a couple of pillows underneath my knees. Many people like to lie on their side with knees bent toward the chest and a pillow between the knees. During those first couple of days, try to get up and slowly move around every few hours. Stand and sit until you become too uncomfortable. Then lie down again. Try to do more each time you get up. What Can I Expect Looking to the Future? Steffens and his colleagues also asked people what they were doing before the low back pain started. Using similar analytic tools as reported here, they hope to find evidence-based triggers. For example, these might include having sex, drinking alcohol, doing a physical task or being overly tired. This new analysis is likely to be published within the next few months.]]>
Fri, 11 Jul 2014 13:14:00 -0400
Doctors' Duty: Protect Brain-Injured Athletes Doctors have a moral duty to help protect athletes from the effects of concussions, a new policy... What Is the Doctor's Reaction? Not so long ago, head injuries were an expected -- and accepted -- part of many sports. Even now, football commentators excitedly talk about someone "having his bell rung" when a head impact leaves a player woozy on the football field. And the opposing player who caused the injury might be praised as tough or fearless. Fortunately, things are changing. We know that repeated concussions and other head injuries can have devastating effects. These effects are now a major focus of concern and research. They include:
  •  Changes in mood or personality
  •  Problems with concentration and learning
  •  Repeated headaches
  •  An increased risk of suicide
  •  Dementia
Neurologists are experts on brain disease and function of the nervous system. They have played a key role in researching the effects of head trauma on brain function. Now the American Academy of Neurology has issued a new report on brain injury. This report goes beyond providing specific medical guidelines for the evaluation and treatment of concussions. It suggests that doctors have an ethical obligation to actively protect athletes from the effects of head injuries. The advice includes these highlights:
  • Doctors should clear an athlete to return to competition only when the athlete is ready.
  • Doctors should resist pressure from coaches, parents or the players themselves to let injured athletes play too soon.
  • Doctors should educate players and parents about the risks of repeated concussions.
  • Training of neurologists should include more about concussions and sports-related head injuries.
  • Athletes should have tests of brain function before competition begins (as a point of comparison).
  • Athletic programs should be required to collect data on concussions as they occur.
Doctors and other health professionals face significant pressures when evaluating an athlete with a head injury. For example, parents or coaches may want a star competitor back on the field when a big game is coming up. Missing games can have a major financial impact on high school athletes hoping to play in college or college athletes hoping to play at a professional level. But I think this new report gets it right: doctors should put the interests of their athlete patients ahead of other concerns when deciding whether they are fit to play. What Changes Can I Make Now? If you or your child takes part in a sport in which head injuries are common, do what you can to reduce risk. This is especially important in football, boxing and ice hockey.
  • Know the rules of the sport, especially ones intended to protect athletes.
  • Know which types of injuries are most likely to cause a concussion.
  • Review the procedures for evaluation and the types of symptoms that should lead to a player's removal from a game.
  • Wear recommended safety equipment (such as a helmet). Wear it properly and wear it every time.
  • Let medical personnel know about any symptoms that occur after a head injury. Follow their advice.
Let your doctor know if you had concussions or other head injuries in the past. A concussion should be suspected after head trauma if any of these symptoms occur:
  • Loss of consciousness
  • Confusion
  • Impaired judgment
  • Poor coordination
  • Poor balance 
Whether you compete or just watch, change how you think about sports head injuries. Understand that an injured player needs to be evaluated before he or she can return to action. It's not a sign of weakness if a player is sidelined for a few plays, the rest of the game or even the rest of the season. And it's not a sign of toughness to return to action right away. Increasingly, it's likely that trainers and doctors will err on the side of caution. They will be more likely to remove players from competition after a head injury. It will be important for players, coaches, parents and spectators to accept this as a necessary change. What Can I Expect Looking to the Future? Almost 4 million sports-related concussions occur in the United States each year. That does not count milder head injuries that might also have long-term effects. As we have recognized the problems these common injuries can cause, some have speculated that high-impact sports, such as football, may become less popular.  I doubt that concerns over head injuries will spell the end of organized football any time soon. But we have already seen changes in how athletes are evaluated and cleared during games. And we've even seen rule changes, such as how football players are allowed to tackle each other. It seems likely that we'll soon see even more changes in screening, evaluating and preventing sports-related head injuries. Research and attention will continue to focus on this issue. And so I hope that in the future we'll also see fewer cases of dementia and psychological problems caused by sports-related head trauma.]]>
Thu, 10 Jul 2014 14:08:00 -0400
Study Raises Heart Concerns for Naproxen Another study has added to the debate about whether some common pain relievers can increase the... increased risk of heart attacks. NSAIDs include ibuprofen (Motrin, Advil and generics) and naproxen (Naprosyn, Aleve and generics). They also include the prescription drug celecoxib (Celebrex). The new study looked at the use of NSAIDs in 160,000 older women. They were part of the Women's Health Initiative study. That study looked at older women's use of hormone therapy. But it also recorded all of the medicines they took. The new study found a higher risk of heart attack and stroke among women who used naproxen or celecoxib. There was no increased risk with use of ibuprofen. Some prior studies have suggested that risk may be greater with ibuprofen than with naproxen. The journal Circulation: Cardiovascular Quality and Outcomes published the study. HealthDay News wrote about it July 8. What Is the Doctor's Reaction? When your joints ache or your head throbs, you might turn to aspirin, ibuprofen (Advil, Motrin) or naproxen (Aleve) for pain relief. They are known as nonsteroidal anti-inflammatory drugs (NSAIDs). Millions of Americans rely on these and other NSAIDs every day. NSAIDs are so widely used because they perform double duty. They relieve pain and also reduce inflammation. All NSAIDs have been linked to have been linked to a greater risk of heart attacks, strokes and heart-related deaths. But naproxen has appeared to pose the least risk, until now. This current research suggests that the heart attack and stroke risk for naproxen might not be any lower. However, the results of this research need to be viewed with caution. The authors analyzed old data from a very large study called the Women's Health Initiative. The study was originally designed to evaluate the effectiveness and safety of hormone therapy in women after menopause.  It was not designed to look at the safety of NSAIDs. This study included more than 160,000 women. Researchers collected many details about the women, including diet, exercise and medicine use. The vast amount of data has been analyzed dozens of times to look for links between behaviors and outcomes unrelated to hormone use. In this instance, researchers discovered a link to higher rates of heart attack and stroke for all NSAIDs other than aspirin. The two most popular NSAIDs are ibuprofen and naproxen. The surprise from this study was the higher risk of heart attack and stroke in naproxen users compared to ibuprofen users. What Changes Can I Make Now? This report won't change the advice I give my patients. The safest way to help ease muscle or joint pain is a non-drug approach. Try heating pads, ice and physical therapy. Even if they don't completely do the trick, they may at least let you cut back on how often you take a pain reliever or how much you take. If you are just looking for pain relief, try acetaminophen first. Acetaminophen kills pain in a different way than NSAIDs. It doesn't increase heart attack risk. And it doesn't irritate the stomach. But acetaminophen does not calm inflammation. In high doses, acetaminophen can cause liver damage. A safe dose for most adults is no more than 3.25 grams per 24 hours (10 regular-strength or 6 extra-strength acetaminophen tablets per day). Don't forget about aspirin. It's a very effective pain reliever and dampens inflammation. And aspirin is the one NSAID that helps prevent heart attacks and strokes. If you need to take more than an occasional aspirin, check with your doctor about the right dose for you. These strategies may not work for you. You may need an NSAID. Occasional use of any of them is likely to be fine. But if you have heart disease or have had a stroke, check with your doctor first. People with kidney disease, stomach ulcers or a history of internal bleeding should avoid NSAIDs. If you take a daily aspirin tablet to prevent clotting and also take an NSAID, take the aspirin first. Wait an hour to take the NSAID. Take both with a little food. What Can I Expect Looking to the Future? The controversy about which is the safest NSAID other than aspirin will continue.]]> Wed, 09 Jul 2014 14:12:00 -0400 Carotid Ultrasound Not Recommended for All Most adults don't need to be tested for narrowing of the arteries leading to the brain, an expert... What Is the Doctor's Reaction? A narrowed carotid artery means you are at increased risk of stroke. Doctors call it carotid artery stenosis. The carotid arteries are the blood vessels in the neck that supply oxygen-rich blood to the brain. To reduce the risk of stroke, you'd think it would always be helpful to find a narrowed carotid artery. Once found, it could be opened with surgery. That's the reason that a new report looks at this question: Should all adults have a screening test to look for carotid artery stenosis, even if they feel fine? The last time the U.S. Preventive Services Task Force formally addressed this question, the answer was no. That was in 2007. The task force recruits experts with different specialties. This reduces the risk of bias, which can happen when just one specialty group issues guidelines. This time, the expert panel once again recommended against routine screening. The updated advice was posted for public comment earlier this year. Now, the advice is official. The test used most often to look for carotid artery stenosis is an ultrasound. The test itself is safe and painless. A doctor or technician puts a wand on each side of the neck. It sends out radio waves to see if there is any narrowing of the carotid artery. There is no radiation. Based on the images, the doctor can estimate the amount of narrowing. But the test is not "harmless." The ultrasound pictures may suggest a greater narrowing than actually exists. This means more testing and potentially surgery. The task force provided these reasons for recommending against screening for all adults:
  • Only a small number of strokes are directly related to a carotid artery narrowing of 70% or greater. (Doctors consider surgery to open the artery if it is narrowed 70% or more.)
  • Less than 1% of the general population has carotid artery stenosis of 70% or greater.
  • High blood pressure, high cholesterol, atrial fibrillation (an irregular heartbeat) and diabetes pose a greater risk of stroke than a narrowed carotid artery.
  • For those without symptoms, surgery provides only a small improvement in stroke risk compared with just taking medicine.
  • The procedure to open the artery carries a risk of stroke, heart attack and death during and right after the surgery.
What Changes Can I Make Now? The task force advice applies only to routine screening for carotid artery stenosis. An ultrasound of the neck remains an important test for anyone with symptoms that suggest a stroke, even if those symptoms last only a few minutes. In these cases, surgery to open the artery may be needed. Your doctor may have ordered an ultrasound of your neck arteries for some other reason besides symptoms. Here are some possible reasons:
  • Your doctor listens with a stethoscope to your neck and hears a whooshing sound called a bruit. This sound is almost always produced by a narrowed artery.
  • You have had a heart attack or have known coronary artery disease or other artery disease.
  • You have factors that increase your risk of stroke, such as:
    • A family history of heart attack or stroke before age 55 for a man or 60 for a woman
    • Smoking
    • Diabetes
    • High blood pressure
    • High LDL ("bad cholesterol"), especially if HDL ("good cholesterol") is low
If you have had an ultrasound that shows a narrowed carotid artery, it does not mean you need surgery to open the artery. The narrowing is caused by fatty deposits inside the carotid artery. And it's also happening in a lot of your other arteries as well. This includes the coronary arteries that feed oxygen and nutrients to the heart. Take action. You can reduce these fatty deposits and prevent new ones. Here's how:
  • Don't smoke.
  • Stick to a heart-healthy diet, such as a Mediterranean-style diet.
  • Maintain a healthy weight to help prevent diabetes.
  • Stay physically active and exercise regularly.
  • Keep your blood pressure under control.
  • Lower your LDL cholesterol, with medicine if necessary. The best medicine is a statin drug.
Low-dose aspirin can help prevent strokes and heart attacks in people with carotid artery stenosis. Ask your doctor if that's the right treatment for you. If you have atrial fibrillation, you are likely to form blood clots inside your heart. These can break away, travel to the brain and cause a stroke. Your doctor will likely recommend medicine to help prevent blood clots from forming. What Can I Expect Looking to the Future? Surgery to open a carotid artery is being performed much less often today than it was 10 to 20 years ago. But for people with a minor stroke or temporary stroke symptoms, surgery may be the best option. Carotid artery surgery is safer now than ever before. It is safest when your surgeon and the hospital have a lot of experience doing the procedure. If you need this procedure, ask your surgeon how many he or she has done. Better outcomes are linked with a higher number of carotid surgeries performed. There are no specific guidelines as to the exact number to use. I suggest at least 10 a year, or more than 50 in the last 5 years.]]>
Tue, 08 Jul 2014 19:43:00 -0400
Steroid Shots May Not Improve Back Pain A new study suggests that steroid shots may not help people with a common back pain problem. The... What Is the Doctor's Reaction? Back pain is remarkably common. Most people, at some point in their lives, will have back pain severe enough to seek medical attention. Standard medicines and physical therapy don't always reduce the most common types of back pain. When that happens, spinal injections are often used. Generally, they include a corticosteroid drug plus a numbing medicine, such as lidocaine. Doctors use high-tech pictures to guide the needle. Injections are made into the joints at the back of the spine or into the space near the spinal cord. The goal is to reduce inflammation and interrupt the pain signals from compressed or irritated nerves. It's considered a safe treatment as long as proper precautions are taken and the injections aren't repeated too often. But a new study calls into question just how good these injections are for one spinal condition, lumbar spinal stenosis. With this condition, the spinal cord in the lower back is compressed. Causes include arthritis, calcium buildup in ligaments and disk disease. Sometimes the narrowing is present from birth and gets worse with age. Symptoms include pain in the back, legs or both. The pain is worse when standing or walking and better when sitting or leaning forward. The definitive treatment is surgery. This is a major operation. Therefore it's usually considered a last resort. In this new study, researchers gave epidural injections to 400 people with lumbar spinal stenosis. They used either the standard combination of drugs or lidocaine alone. Lidocaine is a short-acting anesthetic that would not be expected to provide lasting relief.  So, the lidocaine-only treatment is a useful comparison group. Six weeks later:
  • People in both groups reported improvement. For example, on a scale of 0 to 10, the average person's pain improved from 7 to 4.5.
  • Those receiving both drugs did not report any more  improvement in pain than those receiving lidocaine alone.
  • Responses to questions about disability were similar between the two groups.
  • There were more reported side effects (including headache and infections) in the combination treatment group.  Side effects were minor and did not last.
Despite these findings, I think it's too soon to give up on these injections. Here's why:
  • Although the two treatment groups were similar at 6 weeks, both groups were better than before the injections.
  • A majority of patients were satisfied with their treatment. More people receiving the combination treatment reported satisfaction than the lidocaine-only group (67% vs. 54%).
  • People in this study had moderate to severe leg pain and disability. Others who had milder symptoms or different spine conditions might be more responsive to treatment.
  • People received only 1 or 2 injections over 3 weeks. It's common to offer a third injection, especially if there was at least some improvement with the first ones.
  • The study was not large enough to predict which people are more likely to improve than others.
Still, if other researchers confirm these findings, we may need to reconsider this common treatment.  And that's a big deal for the millions of people who receive these injections in the United States each year. What Changes Can I Make Now? See your doctor if you have unexplained and lasting back or leg pain. It's important to do this right away if you have "red flag" symptoms such as:
  • Fever
  • Recent, significant trauma
  • A prior history of cancer
  • Leg weakness or numbness
  • Loss of ability to control your urine or bowels
  • Unexplained weight loss
The common causes of back pain, such as arthritis or muscle spasm, can usually be well-treated with conservative measures. These include:
  • Analgesics, such as acetaminophen (Tylenol and others)
  • Anti-inflammatory medicines, such as ibuprofen or naproxen
  • Muscle relaxants
  • Heat
  • Physical therapy or stretching
If your doctor recommends epidural steroid injections, ask about this study. As with any elective procedure, discuss the risks, benefits and other treatment options. In 2012, a multistate outbreak of fungal infections after epidural steroid injections affected 751 people. These infections caused 64 deaths. It was a reminder that serious complications can occur. This outbreak was traced back to contaminated medicines from a Massachusetts compounding pharmacy that did not follow standard precautions. Fortunately, such infections are quite rare. What Can I Expect Looking to the Future? This study may lead to a drop in the popularity of epidural steroid injections. This may be appropriate. But the study also raises question for future research to address: 
  • Should injections be offered that contain only lidocaine? 
  • Is it possible to identify which people are most likely to be helped by epidural spinal injections?
  • If steroid injections don't help, what else can a person with lumbar spinal stenosis do (short of surgery) to get relief? 
We need larger and longer-term studies to sort out the role of these injections for spinal stenosis and other spinal conditions.]]>
Thu, 03 Jul 2014 14:10:00 -0400
Transplant May Help Adults with Sickle Cell A partial transplant of bone-marrow stem cells may reverse sickle cell disease in adults, a new... What Is the Doctor's Reaction? In the United States, more than 90,000 people are affected by sickle cell disease. Most of them are African-American. Worldwide, the number is much higher. About 300,000 babies are born with this genetic disease every year. In sickle cell disease, the red blood cells made in the bone marrow are abnormal. Instead of having a normal round shape, the cells are curved and stiff. This causes the red blood cells to get stuck inside blood vessels before they reach the tissues. The result:
  • Damage to organs
  • A high risk of strokes
  • Loss of vision
  • Frequent episodes of very severe pain
Sickle cell disease used to be thought of as incurable. No longer. Bone marrow stem cell transplant has been shown to be more than 90% successful in children. But the treatment requires a complete wipe-out of bone marrow cells. After the transplant, the child must stay on drugs that suppress the immune system indefinitely. This is needed to prevent rejection of the bone marrow transplant. These drugs put the child at high risk for severe infections. Another serious problem that can occur after stem cell transplant is graft-versus-host disease. The transplanted red cells from the donor attack the child's body. This causes a wide variety of medical problems. Adults with severe sickle cell disease already have organ damage. Therefore, a full wipe-out of the bone marrow has seemed too risky for them. But what if a stem cell transplant could be performed without totally wiping out the bone marrow? In this new study, researchers recruited 30 adults with severe sickle cell disease who were willing to undergo this partial bone marrow wipe-out and stem cell transplant. Although the study includes only a small number of patients, the results are dramatic. After 3.4 years, 1 person died. That death was probably unrelated to the stem cell transplant. The amount of medicine needed after the transplant to treat sickle cell pain fell by 80%. And the number of times people needed hospital treatment for severe pain episodes also decreased significantly. People's quality of life improved. Half of them also were able to stop anti-rejection drugs after a year. The patients still had some of their original bone marrow cells. These cells and the donors' bone marrow cells were able to work together naturally to produce enough normal red cells to treat the disease. What Changes Can I Make Now? Most adults with sickle cell disease will not be candidates for this treatment. They need to have a brother or sister who is a match for a bone-marrow stem cell donation. This means the sibling's cells have to be genetically very similar to the patient's cells. This doesn't happen very often. If you do have sickle cell anemia, it's important to do what you can to stay healthy. Here are some things you can do:
  • Take folic acid pills. This vitamin is needed to make red blood cells.
  • Get vaccinated against influenza, pneumonia and other infections.
  • Get regular eye exams. Early detection of injury to the retina can lead to vision-saving laser treatment.
  • Consider hydroxyurea treatment. This medicine may reduce painful episodes, called "sickle crises." You also may need fewer blood transfusions.
  • Get prompt medical care if you have fever or severe pain. Treatment may include fluids, oxygen, transfusions and pain medicines.
What Can I Expect Looking to the Future? Future research will look at whether a parent can act as the stem cell donor. This will require new techniques that either:
  • Alter the parent's donor stem cells to more closely match the patient's cells OR
  • Prevent the patient from rejecting the parent's donated stem cells
This would be a tremendous advance. Many more sickle cell patients might be eligible for stem cell transplant.]]>
Wed, 02 Jul 2014 14:03:00 -0400
Doctors Say Routine Pelvic Exam Not Needed Women don't need annual pelvic exams, a large group of primary-care doctors says. The American... What Is the Doctor's Reaction? For men, the rectal exam is no longer a required part of the routine check-up. In the past, it was done primarily to feel the prostate gland. However, like blood PSA testing, the rectal exam is not an effective prostate cancer screening method. Still, many doctors advise their male patients to have it done. It's a ritual that doctors learned in medical school. And it's hard to just "let it go." Meanwhile, otherwise healthy, non-pregnant women continue to have routine pelvic exams. Many women have them each year. The pelvic exam includes a close look at the vagina and cervix using a speculum. This is followed by the gloved examination inside the vagina, during which the doctor feels:
  • The cervix
  • The uterus
  • Both sides of the lower abdomen in the area where the ovaries and fallopian tubes are located
As they did with the rectal exam for men, researchers began questioning the value of the routine pelvic exam. Is it just a ritual because it seems the right thing to do? Or is there evidence to support its benefit? According to the American College of Physicians (ACP), the evidence for benefit is not there. This group recommends against routine pelvic exams for non-pregnant women who feel fine. They based this advice on a systematic review of prior studies. They not only found no benefit, they found that the exam often causes discomfort and distress. Sometimes it also leads to surgery that is not needed. Since I don't need to undergo the pelvic exam ritual, I called a couple of my female doctor colleagues to get their personal and professional reactions. Question: "Will you miss not having regular pelvic exams?" Response (paraphrased): Are you serious? No way will I miss them! On further discussion with a fellow primary care doctor, we did acknowledge that some women will feel their check-up is not complete without a pelvic exam. What Changes Can I Make Now? You may not need routine pelvic exams. But you still need regular screening for cervical cancer. It can save your life. Here are the screening guidelines for women at average risk of cervical cancer:
  • Women ages 21 to 29 should have a Pap smear once every 3 years.
  • Women ages 30 to 65 should have a Pap smear every 3 years or a Pap smear and a human papilloma virus (HPV) test every 5 years.
  • Women ages 65 and older do not need routine screening if recent Pap smears have been normal.
These are guidelines. For personal reasons, you and your doctor may wish to choose HPV testing first or have more frequent Pap smears than recommended. Pelvic exams will always remain an important part of the diagnostic evaluation for any symptoms that could be related to the vagina, cervix, uterus, fallopian tubes or ovaries. However, if you are an otherwise healthy, non-pregnant woman, you may not need routine pelvic exams. You and your doctor can decide. If your doctor does wish to perform the exam during a routine appointment, feel free to ask why you need it. You can also ask what the doctor is looking for. That's not a challenge. Based on current evidence, there should be a reason for doing a routine pelvic exam. What Can I Expect Looking to the Future? Doctors will likely be slow to let go of the ritual of the routine pelvic exam. I base this on my own approach to screening rectal exams in men. I still offer men a rectal exam as part of routine check-up. I do this because some men feel the check-up is not complete without a rectal exam. And I know they would not comfortable asking me for it. The American College of Obstetricians and Gynecologists (ACOG) still recommends a yearly pelvic exam for women. However, this group does say that evidence does not support or disprove its value. I suspect the current ACOG advice will not change in the near future.]]>
Tue, 01 Jul 2014 14:13:00 -0400
CDC: Alcohol Linked to 1 in 10 Deaths About 1 out of 10 deaths of working-age U.S. adults is linked to excess drinking of alcohol,... What Is the Doctor's Reaction? One out of 10 deaths among working-age adults (ages 20-64) is caused by alcohol. This is found in a new report from the U.S. Centers for Disease Control and Prevention (CDC). Some of the deaths are from motor vehicle accidents. But most are from medical illnesses, such as liver disease or heart failure. Americans may be seriously surprised by this statistic. But as a doctor, I am not surprised at all. Alcohol abuse is commonly a well-hidden habit. An alcoholic who is functioning well may be able to hide the extent of his or her drinking. When not functioning well, an alcoholic may become disengaged and isolated from family and friends. But we doctors see the heavy drinkers. We see them in the hospital, in the emergency room and in the clinic. Family members often remark that their family member seemed "too intelligent" or had "too many resources" to become an alcoholic. But alcoholism can happen to anyone. Some of the people I have known who died from alcoholic liver failure were remarkable successes before their heavy drinking. They included a lawyer, an author and a newspaper editor. Alcohol does not discriminate. Except in one way -- heavy drinking is more likely to cause illness and death in women. Why is this? Women absorb alcohol more easily into their bloodstreams. When a woman drinks the same amount of alcohol as a man, she will have roughly double the blood alcohol level. Most doctors say drinking is safe when kept to these limits:
  • For men, an average of 2 drinks per day (no more than 14 drinks per week), and never more than 4 drinks at a time
  • For women, an average of 1 drink per day (no more than 7 drinks per week), and never more than 3 drinks at a time
What Changes Can I Make Now? If you are dependent on alcohol and you don't stop drinking, your life expectancy may be shortened by up to 30 years, the CDC says. But quitting alcohol is not easy. A long-term support program, such as Alcoholics Anonymous, is likely to be helpful. About half of the people who visit their first AA meeting find it helpful or appealing enough to remain active with the group for at least several months. A hospital alcohol "detox" program is also a good way to quit. Treatment for depression is needed if this part of what has led to your alcohol abuse. Some drinkers take prescription medicines to help them quit. A report published May 14 in the Journal of the American Medical Association summarizes the research on how effective these drugs are. Researchers analyzed the results of 123 studies. One drug, disulfiram (Antabuse) did not score well. This drug creates unpleasant symptoms after a person drinks alcohol. It has been used often in the past to treat alcohol dependence. But researchers said there's not enough evidence of benefit to make it a good choice today. Two drugs have the most proven benefit:
  • Acamprosate (Campral) reduces heavy drinking and risk of relapse. It can also reduce withdrawal symptoms. 
  • Naltrexone (ReVia, Depade) blunts the amount of pleasure that alcohol triggers in the brain. It reduces cravings and gives people more control over urges to drink. In at least 2 studies, people taking naltrexone pills were twice as likely to remain off alcohol for 6 months or longer as people who were given a placebo pill.
These 2 drugs seem to have a roughly equal benefit. Both prevent relapse in about 1 out of 12 people treated. Both can also help alcoholics to avoid heavy binge drinking, even if they relapse to some drinking. One of the most important first steps you can take to stop drinking is to share your planning with another person. This may be a family member, close friend or your doctor. If you join an AA group, it may be your AA sponsor. It is easy to drink when you are alone, but it is hard to break away from drinking when you are alone. What Can I Expect Looking to the Future? Nalmefene (Selincro) is a drug that became available in some European countries a year ago. It is not currently sold in the United States in pill form, but this might occur soon. Nalmefene is intended to reduce the amount of alcohol a person drinks. It does not help someone quit completely. This has made it an attractive option to people who only want to cut down how much they drink. This pill is taken once daily on days when people feel they are likely to drink. It blocks opioid receptors on brain cells. This blunts the emotional feeling of "reward" that can come with drinking. Nalmefene seems to successfully reduce the number of heavy-drinking days per month and number of drinks on drinking days. One out of 12 people taking this medicine had to stop because of side effects such as nausea, dizziness, headache, insomnia or confusion.  Side effects were more common with this drug than with naltrexone. If nalmefene becomes available in the United States, there is a chance it may reduce early deaths from alcohol.]]>
Fri, 27 Jun 2014 20:15:00 -0400
Study: TV May Boost Risk of Early Death Spending a lot of time in front of the TV could increase your risk of early death, a new study... What Is the Doctor's Reaction? You've probably heard this before: exercise is good for you.  The converse is also true: too much inactivity is bad for you. But are some sedentary activities worse than others? For example, is watching a lot of television worse for your health than staring at a computer screen for long hours? That's just what researchers in Spain set out to answer. The Journal of the American Heart Association published the results this week. The study enrolled more than 13,000 young and middle-aged adults. Their average age was 37.  People were asked about their how much time they spent watching TV, using a computer and driving. When considering rates of death, it seemed that watching a lot of TV was worse than using a computer or driving. Eight years after the first survey:
  • People who reported watching 3 or more hours of TV each day had twice the risk of death as those watching less than an hour of TV each day.
  • People who spent the most time driving or using a computer did not have higher rates of death than those spending less time at these activities.
  • The higher rate of death among heavy TV viewers did not seem related to less physical activity, heavier weight (higher body mass index) or higher rates of smoking.
Keep in mind that a study of this sort can only show a link between watching more TV and having a higher risk of death. It cannot prove that watching TV actually caused the higher risk of death. Also remember that people were asked about their activities at only one point in time. In later years, the amount of time spent sitting still or exercising could have changed dramatically.  This study included relatively young adults whose overall death rate was quite low. Less than 1% of study subjects died during the follow-up period.  It is challenging to sort out how particular activities affect the risk of death among such a small sample. Finally, this study accounted for some factors (such as smoking) but not others that could have affected the results. The authors did not account for family history, cholesterol levels and blood pressure, among others. It's possible that TV watchers, for example, had higher blood pressure. Each of these factors could introduce significant error into the study's conclusions. Still, the findings are intriguing -- and hard to ignore. Whether or not watching TV contributes to the early deaths of young and middle-aged adults, previous research is compelling. We know that getting regular exercise and sitting still less are important ways to improve your health and perhaps prolong your life. What Changes Can I Make Now? The authors of this study suggest limiting TV to "no longer than one to two hours each day." But I think it's far more complicated than that. The impact of reducing your TV watching from three to two hours a day would probably be quite small.  And the benefits you get from cutting back on TV will depend at last in part on what you do with that time instead. Most people cannot (and would not want to) completely eliminate inactivity from their lives. But you can make changes to increase your chances of living a long, healthy life. Here's what you can do:
  • Exercise regularly. The American Heart Association suggests:
    • Aerobic exercise for at least two and a half hours a week (or half that if it's high intensity)
    • Muscle strengthening two or more days each week
  • Don't smoke. If you smoke, quitting is the biggest thing you can do to improve your health.
  • Maintain a healthy weight.
  • Keep your blood pressure, cholesterol levels and blood sugar in a good range.
  • Get screened for cancer and other diseases, and get vaccinated as recommended by your doctor.
Let your doctor know about any symptoms you are having. "Toughing it out" or wishing symptoms away is often not the best strategy. What Can I Expect Looking to the Future? The possibility that watching TV increases the risk of early death is not just intriguing -- it's worrisome as well. I'm all for encouraging less TV. But it's not clear to me why watching too much TV can double your risk of early death while equal or longer hours of computer work does not. And what conditions actually cause the early deaths of heavy TV watchers?  Is it heart disease, stroke, cancer or something else? This study was too small to provide definite answers. We need more research to confirm the findings of this latest research. But we also need studies to answer why and how watching TV might shorten a person's lifespan. It's possible that in the future, as TV becomes more interactive, we might even figure out a way to watch our favorite shows with less inactivity -- and less risk.]]>
Thu, 26 Jun 2014 14:06:00 -0400
Cuff Size Affects Blood Pressure Accuracy Taking your blood pressure can help diagnose a problem that could increase your risk of stroke and... What Is the Doctor's Reaction? Any chance you get to measure your blood pressure for free, do it. That includes using a machine in a kiosk. Many pharmacies have them available. As the Food and Drug Administration warns, the reading may not be completely accurate for some people. But for most, the reading from a kiosk blood pressure machine will be accurate and valuable. When readings are inaccurate, it's not because the machine is faulty. That happens rarely. The problem is almost always the cuff size. The cuff is probably too big or too small for your arm. And you can't change the size of the cuff in the kiosk machines. If your arm is thick and barely fits, the blood pressure that shows on the machine may be higher than your real blood pressure. Don't be alarmed. Just arrange to get it checked with the right-size cuff. If you can, have it done by a health professional. The greater concern is for people with thin arms and a cuff that is too large for them. You probably can tell the cuff is too big for you if it takes a very long time for the cuff to inflate and compress your arm. Or you may not feel as much pressure on your arm as you usually do when getting your blood pressure checked. If the cuff is too big for your arm, you may not get any reading. Or it could show a reading that is falsely normal when you actually have high blood pressure (hypertension). Or the reading may appear so low that you get worried. Again, the solution is having it done with the right-size cuff. The right-size cuff covers 80% of the upper half of your arm. Some blood pressure devices are designed to cover the lower half. The same 80% rule applies. Also, to get the most accurate reading, try to have the cuff touching bare skin. That may not be possible in a public kiosk. At least take off any outer layer of clothing, such as a sweater. What Changes Can I Make Now? The best way to track your blood pressure is with a home device. Before purchasing it, make sure the cuff is the right size for you. There are dozens of different home blood pressure monitors on the market. For best accuracy and ease of use, buy one with a cuff for the upper arm that automatically inflates and that automatically records the pressure. Models that store readings for a week or two can simplify record keeping. The American Heart Association recommends not using wrist or finger home blood pressure monitors. They are not as accurate. 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. Each time you take a reading:
  • Avoid caffeinated or alcoholic beverages, and don't smoke, during the 30 minutes before the test.
  • Sit quietly for five 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 three 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 that your machine is accurate and you are doing it right. What Can I Expect Looking to the Future? Similar to most home electronic devices, the quality and cost of home blood pressure monitors will continue to be reasonable. It's a great investment. The only way to know if your blood pressure is normal is to check it. Keeping your pressure in the normal range is best way to avoid a stroke and help prevent a heart attack, heart failure and early death.]]>
Wed, 25 Jun 2014 14:11:00 -0400
Pacemaker May Aid Women More Than Men A type of pacemaker can help more women with heart failure than men, and yet women are less likely... What Is the Doctor's Reaction? Many women experience heart disease differently than men do. So realizing a woman has a heart problem is often more challenging. For example, women often do not have typical symptoms of the most common heart problem, coronary artery disease. Some women do not have classic, crushing mid-chest pain with exertion or during a heart attack. Instead, they are more likely to have "atypical" symptoms. Common ones are shortness of breath, sudden severe weakness, sweating all over the body and feeling anxious at unexpected times during the day. More recently, we are learning that women can also respond differently to heart disease treatments. For example, prior studies have suggested a special treatment for heart failure appears to work better in women than men. It's called cardiac resynchronization therapy with defibrillator (CRT-D). This study confirms that the therapy not only works better in women, it works much better. All the men and women in the study had heart failure caused by a weak heart. This is called systolic dysfunction. They also had an abnormal electrical pattern on their electrocardiogram (ECG). The abnormal pattern showed that one part of the heart was contracting later than it should with each beat. Normally, the muscles of the two main chambers of the heart are synchronized; they contract at the same time. When the heart muscles are "out of sync," a weak heart pumps blood even less effectively than it would with a normal electrical pattern on ECG. Treatment for these types of patients always includes heart failure drugs. These drugs help them live longer and help protect the heart from getting weaker. But they also receive either a plain implantable defibrillator or a CRT-D. The plain defibrillator shocks the heart if it goes into a life-threatening heart rhythm. The CRT-D stimulates the heart muscles to work together more effectively. It also can shock the heart if needed. The guidelines for which patients should get a CRT-D were based on studies in men. This new study found that women with heart failure and a heart that is out of sync may need a CRT-D based on less stringent criteria. But even based on existing guidelines, women now tend to receive CRT-D's less often than men. What Changes Can I Make Now? If you have heart failure caused by a weak heart, your first goal is to maximize your drug treatment. The drugs for heart failure help you feel better and also prolong your life. Next, find out if your electrocardiogram shows an abnormal pattern that might make you a candidate for a CRT-D. In the right person with heart failure who is taking medicines as prescribed, CRT-D can help:
  • Reduce symptoms such as shortness of breath, fatigue and leg swelling
  • Prolong life
  • Reduce the risk of needing hospital care, increased doses of water pills or both
CRT-D may also prevent heart failure from getting worse. The most common causes of heart failure in the United States, Canada and Europe are coronary artery disease, high blood pressure and excess use of alcohol. Most cases of heart failure can be prevented. Here's what you can do:
  • Eat a healthy diet. Don't take in more calories than you burn.
  • Exercise regularly, starting today.
  • Limit alcohol to an average of one drink a day for women and no more than two per day for men.
  • Get your blood pressure checked regularly. Lower it if necessary.
  • Reduce your cholesterol level if it's high. Take a statin drug if diet alone is not enough.
  • Don't smoke.
What Can I Expect Looking to the Future? More women with heart failure and an abnormal pattern on ECG will be receiving a CRT-D. Further studies will look at whether these less stringent criteria might also be applied to men.]]>
Tue, 24 Jun 2014 13:43:00 -0400
Suicide Attempts Up after Antidepressant Alerts Teens and young adults took fewer antidepressants after the drug labels started warning about an... What Is the Doctor's Reaction? The Food and Drug Administration (FDA) often needs to release warnings about drugs based on reports from doctors of potential side effects. Sometimes the warnings turn out to be right on target. In that case, they are later supported by scientific evidence. For example, the warning about aspirin use in children with high fever was based at first on reports. It surely prevented many cases of a devastating brain condition called Reye syndrome. But other times, scientific studies done later don't support the FDA warning. Rarely, the warning can have harmful results. As these study results show, this is what happened after a warning about SSRIs. SSRI stands for selective serotonin reuptake inhibitors. These are the antidepressants prescribed most often. These drugs are very effective for many people and generally well tolerated. Between the years 1999 and 2004, primary-care doctors and pediatricians were getting more comfortable diagnosing depression. Diagnoses increased steadily in all age groups, especially in teens and young adults. During the same period, there was a parallel increase in the number of antidepressant prescriptions. In 2003, the FDA began to alert doctors to a potential increase in suicide risk among children and teens when starting an SSRI. In 2004, the FDA raised even more concern about SSRI drugs. The agency mandated a warning on SSRI labels. Within months, the number of new depression diagnoses started to fall. It continued to fall quite dramatically in the years after. And so did the number of new prescriptions for antidepressant drugs. The FDA added more fuel to the concern about SSRIs in 2007. That's when it expanded the warning about suicide to include young adults. Certainly the FDA had not intended to make depression treatment less available to those who needed it. The FDA wanted doctors to alert patients that they should immediately report any feelings of wanting to hurt themselves. But many doctors and the public interpreted the FDA warning differently. The message heard was that starting an antidepressant increased the risk of suicide. Was the warning about SSRIs justified? Even if it was justified, should it have been presented very differently to doctors and the public? Even in retrospect, the FDA was right to alert doctors of the potential problem. There were enough reports of suicide attempts soon after starting an SSRI to justify making doctors aware of this relationship. But the FDA could have done a much better job of explaining that this did not mean SSRIs caused more suicide attempts. In fact, these new study results suggest the SSRI warning may have done more harm than good. The warning was justified. But it should have put more emphasis on a different message. The message: Anyone with a new diagnosis of depression needs to be alerted to the possibility of increased suicidal thoughts. This can occur even if no drug therapy is started. And patients need to know they should report those thoughts immediately. When possible, family members also should be alerted. What Changes Can I Make Now? Antidepressants are still an effective and relatively safe treatment for depression. That's especially true compared with the alternative of no care at all. But drug treatment must be done with proper monitoring. Depression treatment does not always mean taking medicines. With mild to moderate depression, talk therapy can work as well as drugs for many people. If an antidepressant medicine is needed, an SSRI is still an excellent first choice. What Can I Expect Looking to the Future? It likely won't happen quickly. But during the next few years, more people with depression will once again be diagnosed and receive the treatment they need. The really good result from this story is the renewed emphasis on the need to immediately report suicidal thoughts. This advice should apply whether or not a new drug is started.]]> Fri, 20 Jun 2014 19:33:00 -0400 Rheumatoid Arthritis Drug May Top Old Drug A newer drug improved symptoms for more people than the usual drug given first to people with... What Is the Doctor's Reaction? What's new in the treatment of rheumatoid arthritis? It's a question I hear often. And the answer has changed a lot in the last 20 years. Research through these years has increased our understanding of the disease. That has led to development of new and highly effective treatments. Since the late 1990s, the U.S. Food and Drug Administration (FDA) has approved 11 new drugs. Rheumatoid arthritis is still not considered a curable disease. Yet these new options have improved the lives of millions of people with the disease. Tofacitinib (brand name Xeljanz) is among the newest drugs. The FDA approved it in November 2012. It works in a different way than other recently approved drugs. It blocks an enzyme called Janus kinase. This stops several chemical messengers from triggering inflammation. Tofacitinib is taken as a pill rather than by injection. That is another way it's different from most of the other recently approved drugs for rheumatoid arthritis. A new study asks an important question that arises with the arrival of any new drug: is it as good as the old ones? Is it possibly even better? New research attempts to answer these questions. The study appears this week in the New England Journal of Medicine. Researchers compared the effectiveness of tofacitinib to that of methotrexate. This drug has been around for decades. It is the most common first choice of treatment for rheumatoid arthritis. The study included nearly 1,000 people with rheumatoid arthritis. After 6 months of treatment:
  • The symptoms and signs of joint inflammation improved more in the tofacitinib-treated group than among those receiving methotrexate.  Compared with methotrexate, twice as many people receiving the approved dose of tofacitinib had 70% improvement. With a higher dose of tofacitinib, 3 times as many people had 70% improvement.
  • The X-rays of people receiving tofacitinib showed less joint damage than those of people treated with methotrexate. The differences were small, however.
  • Herpes zoster (shingles) developed in 4% of the tofacitinib group and 1% of the methotrexate group.
  • Cancer developed in a small number of patients. The rate was slightly higher in those assigned to receive tofacitinib. The numbers were too small to draw definite conclusions about cancer risk.
This study provides important information for people with rheumatoid arthritis and their doctors. In fact, these results suggest that tofacitinib might be considered before methotrexate for a person with newly diagnosed rheumatoid arthritis. However, the side effects and the cost of tofacitinib (about $25,000 to $30,000 a year) will likely slow the acceptance of tofacitinib as a "first-line" drug. What Changes Can I Make Now? The cause of rheumatoid arthritis is not known. Therefore, there is no known way to reliably prevent it.  However, we do know that risk is higher in some groups. These include people who smoke and those who have gum inflammation (gingivitis) caused by particular bacteria. You may be able to reduce your chances of developing rheumatoid arthritis by not smoking and by taking good care of your teeth and gums. You may be able to avoid other common types of arthritis, such as osteoarthritis. Here's what you can do:
  • Avoid excess weight. Obesity increases the risk of osteoarthritis. It is thought that millions of cases could be avoided if more people maintained a healthy weight. And that would reduce the need for hip and knee joint replacements.
  • Avoid joint injury. Joint damage related to trauma can lead to osteoarthritis. Measures to avoid injury include:
    • Proper athletic training
    • Proper athletic technique
    • Not taking unnecessary risks at work or at play
There are more than 100 types of arthritis. Early diagnosis and treatment can make a big difference in how well you feel and how well you can function months or years after symptoms begin. So see your doctor for evaluation if you have major or persistent joint pain, stiffness or swelling. What Can I Expect Looking to the Future? It seems likely that tofacitinib and related drugs will be studied soon for a variety of diseases. Tofacitinib has shown promise for psoriasis and allergic diseases. A related drug, ruxolitinib, has already been approved for a serious blood disorder (called myelofibrosis). It has shown promise in the treatment of psoriasis.  Future research should clarify the potential risks of taking tofacitinib. For example, larger and longer-term studies will be needed to determine whether tofacitinib affects cancer risk. Most of the new medicines for rheumatoid arthritis have been quite expensive and require injections. I hope that more treatments will become available in pill form and that the price will eventually come down. When one of my patients asks me what's new in the treatment of rheumatoid arthritis, it's likely I'll have even more to say in the years ahead.]]>
Thu, 19 Jun 2014 00:00:00 -0400
2 Breast-Cancer Tests for High-Risk Women? A study of women with a high risk of developing breast cancer has found that annual MRI scans find... What Is the Doctor's Reaction? Angelina Jolie went public with her personal decision to have a double mastectomy. For women like her, at high risk of breast cancer, this choice offers the best prevention. However, most women at high risk make different choices. High-risk women more often choose screening methods to detect early breast cancer. The international screening guidelines for high-risk women recommend yearly MRI exams starting no later than age 30. This may or may not include yearly mammograms. These guidelines were developed by the American Cancer Society and the United Kingdom Health Service. MRI uses magnetic fields rather than radiation to create an image of the breast. MRI images provide more detail than mammograms. They detect small cancers that mammograms can miss. The superiority of MRI screening for women with a high risk of breast cancer is not in question. But mammograms expose women to radiation. Are there benefits to having a mammogram that outweigh the admittedly small risk from radiation? That is, do they detect cancers that MRI exams don't find? This report helps answer that question for now. In Canada, the Ontario Breast Screening Program includes both yearly MRI and mammograms in its screening for high-risk women. Women ages 30 to 69 are eligible for the program. MRI detected all of the breast cancers confirmed by biopsy. However, 23 of 35 breast cancers seen on MRI were not found on mammograms. So clearly breast MRI for high-risk women is warranted. What might adding a mammogram to an MRI offer these women? In this study and other studies, breast MRI showed many more false positives than mammograms. False positives are spots that could be cancers. But on further testing, usually biopsy, they are not found to be cancers. Mammograms also can show false positives, but not as often. So perhaps a woman who had a questionable MRI might be spared a biopsy or surgery if her mammogram appeared normal.  What Changes Can I Make Now? You are at high risk of breast cancer if you have a 20% or greater lifetime risk of developing it. Experts generally use the following standards to determine which women belong in that high-risk category:
  • A known genetic risk, as determined by a positive test for mutations in the BRCA1 or BRCA2 genes. The estimated lifetime risk for these women is 40% to 87%.
  • Other strong breast-cancer risk genes or, if you have not been tested, a first-degree relative (parent, sibling or child) who has tested positive for these gene mutations.
  • A lifetime risk of 20% to 25%, as calculated by tools developed by the National Cancer Institute (NCI)  and other organizations. You can find the NCI risk calculator at
  • Radiation therapy delivered to the chest between the ages of 10 and 30. Regular screening is particularly important for survivors of Hodgkin's disease. They have nearly a 50% risk of developing breast cancer.
  • A family cancer syndrome or certain other rare genetic disorders. These conditions may increase breast-cancer risk by causing mutations in genes that suppress tumor growth or cause chromosome damage.
If you are at high risk of breast cancer, you should have breast MRI yearly. You and your doctor can decide if a yearly mammogram is also needed. If you're uncertain about your risk, talk with your doctor. Your risk for breast cancer changes with age and family history. Be sure to update your doctor if new cases of cancer occur in your family. Your doctor may refer you to a genetics counselor for a detailed assessment. What Can I Expect Looking to the Future? The Ontario Breast Cancer Program will continue to offer both MRI and mammograms each year to women at high breast-cancer risk. Future reports on their findings will help determine which women might need only MRI exams and which women would benefit from getting both.]]>
Wed, 18 Jun 2014 13:45:00 -0400
Study: 'Bionic Pancreas' Aids Type 1 Diabetics A "bionic pancreas" can help people with type 1 diabetes control their disease with... What Is the Doctor's Reaction? Wearable devices are very cool. You can track body functions such as heart rate, fitness levels, sleep time and whether you are drinking enough fluids to avoid dehydration. They have become very useful for athletes. And surely future wearables will help keep us healthy and make it easier to manage medical diseases. That reality for people with type 1 diabetes is near. Edward Damiano, Ph.D., and his colleagues have taken the first steps to invent a wearable device and prove that it can greatly improve the management of type 1 diabetes. People with type 1 diabetes stop making insulin. Most often this happens because the body's immune system misfires. Antibodies attack insulin-producing cells in the pancreas. Treatment of type 1 diabetes always requires insulin. The goal is to keep blood sugar as close to normal as possible. At the same time, you need to prevent low blood sugar (hypoglycemia). Most people with type 1 diabetes give themselves shots multiple times per day to control blood sugar. This is a major challenge. Tightly controlling blood sugar almost always means more frequent episodes of low blood sugar. An insulin pump that provides a continuous infusion of insulin under the skin does a better job. But it can't respond to changes in diet, exercise and stress. Dr. Damiano had a special reason to focus his professional life on inventing a device to make blood sugar control easier and safer. His son developed type 1 diabetes before his first birthday. He and his wife, a pediatrician, were well aware of the importance of blood sugar control to avoid more health problems later in life. They had to get up several times every night to check their son's blood sugar level with a skin prick. The "bionic" pancreas is still a bit clunky. It required a blood sugar monitor and two tiny tubes placed under the skin. The tubes were attached to an infusion pump. One tube delivered insulin. The other tube delivered a hormone called glucagon that rapidly raises the blood sugar level. The device under the skin was connected wirelessly to a smart phone. It was programmed to automatically deliver insulin or glucagon when blood sugar levels got too high or too low. The smart phone also was used to tell the device when the person was eating. Acting like a normal pancreas, the device pumped out extra insulin at mealtimes. The beauty of this study was that the researchers tested the device in "real life." People in the study engaged in their usual activities, with few restrictions. People using the device were compared with another group using normal insulin pumps. Comparing average blood sugars and the number of hypoglycemic events, the device performed better on both counts. What Changes Can I Make Now? This type of bionic pancreas won't be available for several years. It needs a lot more refinement and testing. Type 1 diabetes can't be prevented and can't be cured. Meanwhile, control of blood sugar levels will continue to require frequent blood sugar checks. People with type 1 diabetes also must make an extra effort to maintain a consistent diet and exercise schedule. They also must adjust their insulin use when needed. On the other hand, type 2 diabetes can be prevented. And type 2 diabetes is 10 times more common today than type 1 diabetes. A bionic pancreas to pump in more insulin is not an option for people with type 2 diabetes. Early in the disease process, they make plenty of insulin. In fact, they need to make extra insulin to move sugar out of the blood and into cells. This is known as insulin resistance. The way to help prevent type 2 diabetes is to ask your pancreas to make as little insulin as possible to keep blood sugar in the normal range. Of course, you can't command your pancreas to do that. But you can help make it happen.
  • Maintain a healthy body weight.
  • Keep your waistline trim. There is no consensus on an ideal waistline. I suggest less than 30 inches for women and less than 35 inches for men.
  • Stay as physically active as you can throughout the day.
  • Dedicate at least 30 minutes a day, most days of the week, to moderate-intensity exercise. If you need to lose weight, you should strive for 60 minutes daily.
  • Eat and drink fewer products that contain simple sugars and high-fructose corn syrup.
If you have pre-diabetes or a family history of type 2 diabetes, I urge you to take these actions right away. They can help you to lower your blood sugar while asking your pancreas to make less insulin. What Can I Expect Looking to the Future? The bionic pancreas of the future will be all contained in a single device that won’t require a wireless connection.]]>
Tue, 17 Jun 2014 14:05:00 -0400