tag:blogger.com,1999:blog-39467416892712350702024-03-16T11:53:15.785-07:00DrDialogueA Medical BlogJuliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.comBlogger61125tag:blogger.com,1999:blog-3946741689271235070.post-51852626550074114452014-06-15T16:14:00.000-07:002014-06-15T16:14:29.637-07:00Maintaining Adequate Hydration<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEihUY1MVVc04wKIy4bvCAsRmewvvLe0D_eHLuvs1IlGILs7vs5aXsa8lDY28OQ5cr9ZJObwoFfh90ctAI06EpITGZ9WQhwrvO5cHMytbgcfsDR0vEJhcMENuu8AKRmVHULFEOls0SgLozQb/s1600/cups.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEihUY1MVVc04wKIy4bvCAsRmewvvLe0D_eHLuvs1IlGILs7vs5aXsa8lDY28OQ5cr9ZJObwoFfh90ctAI06EpITGZ9WQhwrvO5cHMytbgcfsDR0vEJhcMENuu8AKRmVHULFEOls0SgLozQb/s1600/cups.jpg" /></a></div>
<span style="font-family: Calibri;">Looking around one might think that there is an epidemic of
dehydration plaguing Americans, who tote drinks with them to all locales--cars
and strollers armed with cups holders, hydration stations every mile of a
running race, exercise belts studded with water bottles marketed to the
recreational runner. It seems we might all shrivel up and dehydrate without
this.<span style="mso-spacerun: yes;"> </span></span><br />
<span style="font-family: Calibri;"><span style="mso-spacerun: yes;"></span><o:p></o:p></span><br />
<span style="font-family: Calibri;">We all know that drinking sugary soda is bad for us and has
helped lead to the current obesity epidemic.<span style="mso-spacerun: yes;">
</span>We have been led to believe that incessant water drinking is healthy, but
how much and what does one really need to drink to feel good and prevent
problems? <o:p></o:p></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">As summer approaches
in Hotlanta, my home, I’ve become interested in learning more of the specifics
of what constitutes healthy fluid consumption. In my practice I see patients both
who over-hydrate and those who under-hydrate, each of which can contribute to
medical morbidity. <o:p></o:p></span></div>
<span style="font-family: Calibri;">Humans and other animals are adapted to have finely tuned
physiologic mechanisms to protect against dehydration. The perceived result of
these mechanisms is thirst. <span style="mso-spacerun: yes;"> </span>Studies have
shown that as we age our thirst mechanism becomes less effective, making older
adults particularly sensitive to dehydration.<span style="mso-spacerun: yes;">
</span>According to tables of normative water requirements for men and women by
age and energy expenditure, an average middle aged man <span style="mso-spacerun: yes;"> </span>should consume about 3.7 liters of fluid daily (125
oz. or 15 cups). An average middle aged woman should consume about 2.7 liters
of fluid daily (91 oz. or 11 cups). Of course, fluid requirements also depend
on fluid losses through sweating, which can range from .3 L/hour to 2 L/hour. I
found this reference </span><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2908954/"><span style="color: blue; font-family: Calibri;">Water, Hydration
and Health</span></a><span style="font-family: Calibri;"> to be very informative. <o:p></o:p></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">What constitutes healthy fluid replenishment in the context
of exercise? The American Academy of Sports Medicine recommends that athletes
pre-hydrate 4 hours prior to physical activity with 2-3 mL per pound of body
weight. For me, at 130 pounds, that’s 325 ml of liquid (11 oz., or about a cup
and a half). For a man weighing 200 pounds that’s about 500 ml of liquid (17 oz.,
or about 2 cups). <span style="mso-spacerun: yes;"> </span>Here’s a very good </span><a href="http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0CCYQFjAA&url=http%3A%2F%2Fwww.acsm.org%2Fdocs%2Fbrochures%2Fselecting-and-effectively-using-hydration-for-fitness.pdf&ei=dd2JU9mOJajjsATkjYHwBg&usg=AFQjCNHIvumIOmiugDW70p63_E8LKxJK5A&bvm=bv.67720277,d.cWc"><span style="color: blue; font-family: Calibri;">brochure</span></a><span style="font-family: Calibri;">
on the subject: <o:p></o:p></span></div>
<span style="font-family: Calibri;">During exercise, adequate hydration is defined as preventing
a loss of more than 2% of one’s body weight. Again, using myself as an example at
130 pounds, that’s about 2.5 lbs. I know my usual “hydrated” weight, and
typically weigh myself after exercise and before showering so it’s fairly easy
to monitor my fluid loss.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">According to recent guidelines, rapid and complete recovery
from excessive dehydration can be accomplished by drinking at least 16-24 oz.
(450-675 mL) of fluid for every pound (0.5 kg) of body weight lost during
exercise. What’s the best liquid to consume? At least some of one’s rehydration
should include fluid with electrolytes---sodium and potassium. In addition, carbohydrate
(sugar) in fluid actually helps to replenish glycogen stores, and has been
found to improve athletic performance. Of course, for those who are trying to
lose weight through physical activity, consuming beverages with carbohydrates also
contributes calories, so one needs to be careful about overdoing it with sugary
beverages, including sports drinks like Gatorade or PowerAde. My personal
practice is to consume one bottle or can of salty beverage (500 mL) and
approximately 16 oz. of water after a summer work-out of 45 minute duration (my
most common exercise duration). Drinking a sports drink 30-45 minutes into a
race that’s destined to last more than 60-90 minutes may enhance performance, followed
by drinking water as one is able every 15-30 minutes thereafter. One of my
personal favorite beverages with which to help rehydrate with is V-8 or tomato
juice, which is loaded with sodium and potassium, though the carbohydrate
content is less than Gatorade or PowerAde. I typically drink this along with my
usual 2-3 cups of water after a vigorous 60 minute work-out in the summer.<o:p></o:p></span></div>
<span style="font-family: Calibri;">The risk of excessive water drinking is hyponatremia, which
is known to occur in athletes who exercise in the heat and then re-hydrate with
large amounts of water without salt or electrolyte content quickly. In my
office I also see hyponatremia as a problem for some patients who consume large
amounts of water for health reasons or weight loss (“psychogenic polydipsia”),
or who are on diuretics, which cause loss of sodium.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">The Institute of Medicine recommends the following
composition of sports drinks for prolonged (>60 minutes) physical activity
in hot weather: 20-30 meq/L of sodium, 2-5mEq/L potassium, and 5-10% carb
(>8% may delay gastric emptying).<o:p></o:p></span></div>
<span style="font-family: Calibri;">Here is a comparison of the nutritional content of various
drinks along with an approximate range for the electrolyte content of sweat
(which can vary considerably in sodium content).<span style="mso-spacerun: yes;"> </span>Something interesting that I learned through
reading on this subject is that muscle cramps in athletes seem to correlate
more with sodium loss than potassium loss. As you can see, Gatorade does
approximate the electrolyte content of sweat. <o:p></o:p></span><br />
<br />
<table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: currentColor; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="background-color: transparent; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 85.05pt;" valign="top" width="113"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">Nutritional Content per :<o:p></o:p></span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">1 cup, 8 oz.,<span style="mso-spacerun: yes;"> </span>237 ml<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: windowtext windowtext windowtext rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 83.2pt;" valign="top" width="111"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">Gatorade<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: windowtext windowtext windowtext rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 84pt;" valign="top" width="112"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">Chocolate Milk<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: windowtext windowtext windowtext rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 73.7pt;" valign="top" width="98"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">V-8<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: windowtext windowtext windowtext rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 81.85pt;" valign="top" width="109"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">ZICO: Coconut Water<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: windowtext windowtext windowtext rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 71pt;" valign="top" width="95"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">Sweat (estimate)<o:p></o:p></span></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 85.05pt;" valign="top" width="113"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">Sodium (mg)<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 83.2pt;" valign="top" width="111"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">104.4 mg<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 84pt;" valign="top" width="112"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">152.5 mg<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 73.7pt;" valign="top" width="98"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">640 mg<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 81.85pt;" valign="top" width="109"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">64 mg<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 71pt;" valign="top" width="95"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">~100-300 mg<o:p></o:p></span></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 85.05pt;" valign="top" width="113"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">Potassium (mg)<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 83.2pt;" valign="top" width="111"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">30 mg<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 84pt;" valign="top" width="112"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">425 mg<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 73.7pt;" valign="top" width="98"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">445 mg<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 81.85pt;" valign="top" width="109"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">471.36 mg<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 71pt;" valign="top" width="95"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">~40-60 mg<o:p></o:p></span></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 85.05pt;" valign="top" width="113"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">Carb (gm)<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 83.2pt;" valign="top" width="111"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">14 gm<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 84pt;" valign="top" width="112"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">26 gm<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 73.7pt;" valign="top" width="98"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">9.7 gm<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 81.85pt;" valign="top" width="109"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">10.72 gm<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 71pt;" valign="top" width="95"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><o:p><span style="font-family: Calibri;"> </span></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 4;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 85.05pt;" valign="top" width="113"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">Protein (gm)<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 83.2pt;" valign="top" width="111"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">0<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 84pt;" valign="top" width="112"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">8 gm<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 73.7pt;" valign="top" width="98"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">0<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 81.85pt;" valign="top" width="109"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">0<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 71pt;" valign="top" width="95"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><o:p><span style="font-family: Calibri;"> </span></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 5; mso-yfti-lastrow: yes;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 85.05pt;" valign="top" width="113"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">Fat<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 83.2pt;" valign="top" width="111"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">0<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 84pt;" valign="top" width="112"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">2.5 gm<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 73.7pt;" valign="top" width="98"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">0<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 81.85pt;" valign="top" width="109"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><span style="font-family: Calibri;">0<o:p></o:p></span></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 71pt;" valign="top" width="95"><div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><o:p><span style="font-family: Calibri;"> </span></o:p></span></div>
</td>
</tr>
</tbody></table>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">My conclusion--while the contrarian in me used poke fun at
the ever water-toting health nut, I’ve now become a believer. Personally, I’ve
probably been running on the dry side.<o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
</div>
<div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com0tag:blogger.com,1999:blog-3946741689271235070.post-79850769580319217912014-02-01T13:51:00.002-08:002014-02-01T14:48:56.953-08:00Should you be on cholesterol medication? How the new guidelines are different<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiOZtQEsIVDDTLzCss9SsMejgJC9umWYR2mGozYzexGIMpHWpLphLrg1HkrtkhMUfVbk3Rb0dPYNhQnmuQJePODcFoj5gH03gsWK0xfaReeA692hIwWGTmkDW8dfW1BWM9VYdHsEUAI-mXe/s1600/chol+med.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiOZtQEsIVDDTLzCss9SsMejgJC9umWYR2mGozYzexGIMpHWpLphLrg1HkrtkhMUfVbk3Rb0dPYNhQnmuQJePODcFoj5gH03gsWK0xfaReeA692hIwWGTmkDW8dfW1BWM9VYdHsEUAI-mXe/s1600/chol+med.jpg" /></a></div>
<span style="font-family: Calibri;">Cardiovascular disease—including coronary atherosclerosis
and cerebrovascular disease, remains the number one cause of mortality in the
United States. One out of three people in this country will die of
cardiovascular causes.<span style="mso-spacerun: yes;"> </span>Although I can’t
say that the other top causes of mortality are particularly attractive--cancer,
chronic lung disease, accidents and dementia—premature cardiovascular death can
certainly be very devastating and it makes sense to do our best to prevent it.<o:p></o:p></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">In November 2013 updated guidelines for the treatment of
high cholesterol were released by the American College of Cardiology-American
Heart Association.<span style="mso-spacerun: yes;"> </span>These guidelines were
the subject of <a href="http://blog.heart.org/new-heart-disease-and-stroke-prevention-guidelines-released/">significant controversy</a>.
In contrast to the previous guidelines from 2002, the current guidelines do not
suggest treatment based primarily on numerical cholesterol targets. Rather, the
guidelines stratify people according to determined <u>cardiovascular risk</u>
and recommend either high intensity statin treatment, moderate intensity statin
treatment, or no statin treatment. The guidelines do not support using other types
of cholesterol-lowering drugs because at this point there is not good data to
suggest that using other types of treatments is beneficial in terms of
preventing actual cardiovascular outcomes (heart attack, stroke or
cardiovascular death). This is despite the fact that there are treatments out
there that do lower one’s cholesterol numbers.<o:p></o:p></span></div>
<span style="font-family: Calibri;">How is <u>cardiovascular risk</u> determined? With the new
guidelines, a new risk calculator was proposed. In my clinical practice in the
past I’ve used the <a href="http://cvdrisk.nhlbi.nih.gov/evalData.asp">Framingham Risk Calculator</a></span><span style="font-family: Calibri;">
and the <a href="http://www.reynoldsriskscore.org/">Reynolds Risk Calculator</a> </span><span style="font-family: Calibri;">
. The new risk calculator released with the 2013 guidelines is a bit different.
Some experts have suggested that it overestimates risk. With the new risk
calculator, if one’s ten year risk of a cardiovascular event exceeds 7.5% then
treatment with a statin is recommended.<o:p></o:p></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">The new guidelines divide people into the following groups
of patients between ages 40 and 75 years who are in need of treatment with
statins, or so called “statin benefit groups.”<o:p></o:p></span></div>
<br />
<div class="MsoListParagraphCxSpFirst" style="margin: 0in 0in 0pt 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: Calibri;">Those with LDL over 190mg/dL (high intensity statin
treatment is recommended)<o:p></o:p></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: Calibri;">Those with a ten year risk of >7.5% (moderate
intensity statin treatment is recommended)<o:p></o:p></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: Calibri;">Those with established cardiovascular disease
(high intensity statin treatment is recommended)<o:p></o:p></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: Calibri;">Those with diabetes, in which 10 year risk is
>7.5% (high intensity statin treatment is recommended) <o:p></o:p></span></div>
<br />
<div class="MsoListParagraphCxSpLast" style="margin: 0in 0in 10pt 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: Calibri;">Those with diabetes, in which 10 year risk is
<7 .5="" font="" intensity="" moderate="" statin="">treatment is recommended)<o:p></o:p>
</7></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Click <u><a href="http://my.americanheart.org/professional/StatementsGuidelines/PreventionGuidelines/Prevention-Guidelines_UCM_457698_SubHomePage.jsp">here</a></u> to calculate your risk. </span><span style="font-family: Calibri;">What qualifies as high intensity statin treatment? LDL
lowering of 50% or greater. </span><span style="font-family: Calibri;">What is moderate intensity statin treatment? LDL lowering of
30-50%.</span></div>
<span style="font-family: Calibri;">The guidelines suggest that particular statins may be better
than others at achieving these goals and good outcomes: atorvastatin,
simvastatin, and rosuvastatin.<span style="mso-spacerun: yes;"> </span>Other
statins are typically used when patients experience unwanted side effects, like
muscle pain.<o:p></o:p></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">How are things different with the new guidelines?<o:p></o:p></span></div>
<span style="font-family: Calibri;">Let’s take an example.<span style="mso-spacerun: yes;">
</span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>A 71 year old white female, non-smoker,
non-diabetic, with a history of hypertension, asked me whether or not she
should be treated for high cholesterol. <span style="mso-spacerun: yes;"> </span>She is concerned about her risk of heart
disease, as her mother had a stroke in her 60s and then sudden death, presumed cardiovascular,
at age 83. My patient’s most recent total cholesterol level was 204 mg/dL with
an LDL level of 121 mg/dL and an HDL level of 64 mg/dL.<span style="mso-spacerun: yes;"> </span>A couple of years ago I calculated her
Framingham Risk score, which is 6% with these risk factors. This represents low
to intermediate risk. To get further information I also ordered a coronary
calcium score, which was found to be zero.<span style="mso-spacerun: yes;">
</span>Last year, based on these numbers and the older guidelines, I
recommended against treatment with a statin. <span style="mso-spacerun: yes;"> </span>However, now, based on the new risk assessment
tool, the same patient has a ten year risk of 16%.<span style="mso-spacerun: yes;"> </span>With the new guidelines she would unequivocally
qualify for moderate dose statin.<span style="mso-spacerun: yes;"> </span>At
this point, I am not exactly sure what to do with the coronary calcium score,
which probably projects that her risk is lower than the 16% that the new
equation came up with.<span style="mso-spacerun: yes;"> </span>Nonetheless, I am
not sure that coronary calcium scoring entirely predicts <u>all</u>
cardiovascular risk—for example risk related to small vessel disease and
stroke, so perhaps she should receive treatment.<span style="mso-spacerun: yes;"> </span>Low dose, statin treatment might be a good
compromise here.<o:p></o:p></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Interestingly, based on this new risk calculator virtually
every 71 year old, even with optimal risk factors, would qualify for treatment with
a statin.<span style="mso-spacerun: yes;"> </span>Herein lies the controversy
with this tool.<o:p></o:p></span></div>
<span style="font-family: Calibri;">Nonetheless, my own view of the new guidelines is mostly favorable.
To me it simplifies things based on what we know from numerous well designed
studies. Treatment, with an emphasis on statins, is based on risk projection
and less attention is paid to absolute numbers. <span style="mso-spacerun: yes;"> </span>I hope that the next decade will continue to bring
more a nuanced understanding of risk.<o:p></o:p></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
</div>
<div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com0tag:blogger.com,1999:blog-3946741689271235070.post-7624212353564347422013-08-22T12:55:00.001-07:002013-08-22T12:55:44.125-07:00Should a Doctor Prescribe Drugs that are Unapproved by the FDA ?<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em; text-align: center;">
<img class="rg_i" data-src="https://encrypted-tbn1.gstatic.com/images?q=tbn:ANd9GcSpbr35SRLTZ_-YSe8M73NW-jOeamR7rVKkQrggDhqRpl0XkN5NVQ" data-sz="f" name="3bixPrOtpZ57tM:" sab="1283" src="https://encrypted-tbn1.gstatic.com/images?q=tbn:ANd9GcSpbr35SRLTZ_-YSe8M73NW-jOeamR7rVKkQrggDhqRpl0XkN5NVQ" style="height: 168px; margin-left: -12px; margin-right: -13px; margin-top: 0px; width: 300px;" /></div>
Here’s an interesting clinical dilemma brought to my attention by another physician.<br />
<div>
</div>
<div>
She was asked to refill a prescription for a drug called domperidone to help a patient with lactation. Domperidone is not FDA approved in the United States for any indication. However, in Europe and in Canada it is approved as a promotility agent for patients with a condition called gastroparesis, which causes the stomach to empty very slowly and results in chronic nausea and vomiting. As a side effect the drug is also known to increase the production of prolactin, a hormone that stimulates milk production. In the case of this physician's patient, she had adopted a child and found that the medication had effectively enabled her to produce milk and nurse, with seemingly no untoward effects. It’s unclear who had initially prescribed the drug, but various online <a href="http://www.lllc.ca/information-lllc-re-health-canada-advisory-regarding-domperidone">lactation support forums</a> discuss it as an option for women who have trouble with lactation.</div>
<div>
</div>
<div>
The questions: Is it legal, ethical or good medical practice for a physician in the United States to write a prescription for domperidone for a patient who has been using it for lactation with good results? How about for gastroparesis? Where does one get the drug? Is it even legal to sell the drug in the United States? </div>
<div>
</div>
<div>
I’ve cared for at least two patients who have used domperidone. In both instances it was ordered by prescription from an overseas source by a local gastroenterologist. In these two cases my patients had tried just about everything on the market in the United States for gastroparesis and were still struggling with debilitating symptoms. In one case, my patient had required hospitalizations and ultimately a feeding tube because of intractable vomiting. The drug was ineffective in both patients and it was eventually discontinued. </div>
<div>
</div>
<div>
As I read more about this medication I discovered that the <a href="http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm154914.htm">FDA cautions</a>: </div>
<blockquote class="tr_bq">
"<span style="font-size: x-small;">FDA warned healthcare professionals and breastfeeding women not to use an unapproved drug, domperidone, to increase milk production (lactation). The agency is concerned with the potential public health risks associated with domperidone. FDA took these actions because it has become aware that some women are purchasing this drug from compounding pharmacies and from foreign sources. Although domperidone is approved in several countries outside the U.S. to treat certain gastric disorders, it is not approved in any country, including the U.S., for enhancing breast milk production in lactating women and is also not approved in the U.S. for any indication</span>.”</blockquote>
<div>
The concern over domperidone is its potential to induce potentially <a href="http://www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/referrals/Domperidone-containing_medicines/human_referral_prac_000021.jsp&mid=WC0b01ac05805c516f">fatal cardiac arrhythmias</a> through QT prolongation (an alteration of electrical activity in the heart). This risk has been recognized in Europe and is currently under study. Nonetheless, at least <a href="http://rcp.nshealth.ca/news/ilca-consensus-domperidone-support-lactation">one expert panel in Canada</a> has endorsed the safety of the drug for use in lactation (though not currently approved for this use in Canada). </div>
<div>
</div>
<div>
As my colleague and I discussed the situation with her patient we both concluded that it would not be prudent to refill this prescription for the purpose of lactation. In fact, it would likely be construed as medical malpractice, in light of the drug’s status with the FDA, should the patient or her baby suffer any toxicity. However, clearly there are gastroenterologists who feel that prescribing this medication in United States for cases of severe gastroparesis is justifiable—and I would concur that in certain situations this might be a compassionate and reasonable option despite the regulatory concerns. </div>
<div>
</div>
<div>
To further extend this discussion—physicians do frequently prescribe drugs that are on the market and FDA approved for off-label use. For example, just yesterday I prescribed gabapentin for hot flashes. One interesting study published in <a href="http://archinte.jamanetwork.com/article.aspx?articleid=410250">Archives of Internal Medicine in 2006 by Radley, Finkelstein, and Stafford</a> found that 21% of sampled medications were being prescribed for off-label use. </div>
<div>
</div>
<div>
The authors concluded:</div>
<blockquote class="tr_bq">
"<span style="font-size: x-small;">The Food and Drug Administration (FDA) focuses on market entry for prescription drugs rather than regulating physicians' prescribing practices, allowing off-label use of medications for indications beyond those formally evaluated by the manufacturer. Off-label prescribing of medications is legal,</span><a href="http://archinte.jamanetwork.com/article.aspx?articleid=410250#ref-ioi50251-1"><span style="font-size: x-small;">1</span></a><span style="font-size: x-small;"> often thought to be supported by scientific evidence,</span><a href="http://archinte.jamanetwork.com/article.aspx?articleid=410250#ref-ioi50251-2"><span style="font-size: x-small;">2</span></a><span style="font-size: x-small;"> and common in certain clinical settings.</span><a href="http://archinte.jamanetwork.com/article.aspx?articleid=410250#ref-ioi50251-3"><span style="font-size: x-small;">3</span></a><span style="font-size: x-small;">- </span><a href="http://archinte.jamanetwork.com/article.aspx?articleid=410250#ref-ioi50251-3"><span style="font-size: x-small;">4</span></a><span style="font-size: x-small;"> Although this practice provides a pathway to innovation in clinical practice, it raises key concerns about risks to patients and costs to the health care system.</span><a href="http://archinte.jamanetwork.com/article.aspx?articleid=410250#ref-ioi50251-5"><span style="font-size: x-small;">5</span></a><span style="font-size: x-small;">- </span><a href="http://archinte.jamanetwork.com/article.aspx?articleid=410250#ref-ioi50251-5"><span style="font-size: x-small;">7</span></a>"</blockquote>
<div>
Whereas prescribing approved medications for off-label use falls into the realm of acceptable clinical practice, one has to be very circumspect about prescribing drugs that are not deemed adequately safe or effective to market in the United States for any indication.
Unfortunately for those who feel that the FDA is too slow, political, or conservative in its approval process, these are the regulatory constraints under which physicians must practice in the United States.
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"></span> </div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<sup><o:p><span style="font-family: Calibri; font-size: x-small;"> </span></o:p></sup></div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
<div>
</div>
</div>
<div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com1tag:blogger.com,1999:blog-3946741689271235070.post-39209756391921383012013-07-03T12:55:00.002-07:002013-07-03T12:55:44.342-07:00What foods are in the Mediterranean Diet ?<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" sab="1025" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhoVhMunL-xs8FAwCqxNZVk0pY_xIO8Z9LkcXaESToY9eQqJ_CfyVuAQCQrD2Le01v65CIBNCM9t7KMaEiYQNSnNpO4_iP1DpfRpsX0fiN3cWIhF5BP0gwc2QpgdudmnIQGDNblALl1N-zI/s720/octopus+saved.jpg" imageanchor="1" sab="1026" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhoVhMunL-xs8FAwCqxNZVk0pY_xIO8Z9LkcXaESToY9eQqJ_CfyVuAQCQrD2Le01v65CIBNCM9t7KMaEiYQNSnNpO4_iP1DpfRpsX0fiN3cWIhF5BP0gwc2QpgdudmnIQGDNblALl1N-zI/s720/octopus+saved.jpg" height="240" sab="1027" width="320" /></a></div>
<div sab="736">
<div sab="864">
<span sab="737" style="font-family: Calibri;">The Mediterranean Diet is fresh on my mind, having recently
returned from a trip to Turkey.<span sab="738" style="mso-spacerun: yes;"> </span>During
my trip I became a particular fan of Turkish vegetables—white beans with
tomatoes and onions in olive oil, oven baked green beans or okra, eggplant
stuffed with walnuts with a tomato ragout, to name a few. My husband commented
that I must be a true fan of olives, as he surveyed my breakfast plate, which
was chalk full of several varieties of olives, raw cucumbers, tomatoes, a few
arugula leaves, fresh cheese and bread.<span sab="739" style="mso-spacerun: yes;">
</span>During my travels I also enjoyed a variety of grilled fresh fish served with
lemon, seaweed salad, pomegranate juice, freshly pressed at the side of road,
and roasted chestnuts, also sold by street vendors. <o:p sab="740"></o:p></span></div>
</div>
<div sab="741">
<div sab="870">
<br /></div>
</div>
<div class="MsoNormal" sab="742" style="margin: 0in 0in 10pt;">
<div sab="743">
<div sab="873">
<span sab="744" style="font-family: Calibri;">I was elated to hear that a new study published in the <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1200303" sab="745">New England Journal of Medicine</a> in April of this year </span><span sab="746" style="font-family: Calibri;">
validated the health benefits of the Mediterranean diet. The study randomized
7447 women and men with risk factors for cardiovascular disease to receive either a Mediterranean diet enriched with olive
oil, a Mediterranean diet enriched with nuts, or a standard low fat diet
for the control group. Participants assigned to the two Mediterranean diet arms were
found to have a significantly reduced risk of adverse cardiovascular outcomes
(heart attack, stroke, death from cardiovascular causes) compared with the
control group. The study was terminated after a mean follow up time of 4.8 years.</span></div>
</div>
</div>
<div class="MsoNormal" sab="747" style="margin: 0in 0in 10pt;">
<div sab="748">
<div sab="879">
<span sab="749" style="font-family: Calibri;"><span sab="750" style="mso-spacerun: yes;"> </span>Are you wondering how
your diet matches up with the “Mediterranean Diet” as defined by the recent
study? I was after I read these results.</span></div>
</div>
</div>
<div class="MsoNormal" sab="751" style="margin: 0in 0in 10pt;">
<div sab="752">
<div sab="884">
<span sab="753" style="font-family: Calibri;">Here are the criteria with answers qualifying for the
Mediterranean Diet shown in bold.</span></div>
</div>
</div>
<div class="MsoNormal" sab="756" style="margin: 0in 0in 10pt;">
<div sab="757">
<div sab="888">
<span sab="758" style="font-family: Calibri;">1. Do you use olive oil as main culinary fat?<span sab="759" style="mso-spacerun: yes;"> </span><b sab="760" style="mso-bidi-font-weight: normal;"><i sab="761" style="mso-bidi-font-style: normal;">Yes</i></b><i sab="762" style="mso-bidi-font-style: normal;"> </i></span></div>
</div>
</div>
<div class="MsoNormal" sab="765" style="margin: 0in 0in 10pt;">
<div sab="766">
<div sab="896">
<span sab="767" style="font-family: Calibri;">2. How much olive oil do you consume in a given day
(including oil used for frying, salads, out of house meals, etc.)?<span sab="768" style="mso-spacerun: yes;"> </span><b sab="769" style="mso-bidi-font-weight: normal;"><i sab="770" style="mso-bidi-font-style: normal;">4 or more tablespoons</i></b> </span></div>
</div>
</div>
<div class="MsoNormal" sab="773" style="margin: 0in 0in 10pt;">
<div sab="774">
<div sab="903">
<span sab="775" style="font-family: Calibri;">3. How many vegetable servings do you consume per day? (1
serving = 200g - consider side dishes as 1/2 serving)<span sab="776" style="mso-spacerun: yes;"> </span><b sab="777" style="mso-bidi-font-weight: normal;"><i sab="778" style="mso-bidi-font-style: normal;">2 or more (at least 1 portion raw or as
salad)</i></b><i sab="779" style="mso-bidi-font-style: normal;"> </i></span></div>
</div>
</div>
<div class="MsoNormal" sab="782" style="margin: 0in 0in 10pt;">
<div sab="783">
<div sab="911">
<span sab="784" style="font-family: Calibri;">4. How many fruit units (including natural fruit juices) do
you consume per day?<span sab="785" style="mso-spacerun: yes;"> </span><b sab="786" style="mso-bidi-font-weight: normal;"><i sab="787" style="mso-bidi-font-style: normal;">3 or
more</i></b></span></div>
</div>
</div>
<div class="MsoNormal" sab="790" style="margin: 0in 0in 10pt;">
<div sab="791">
<div sab="918">
<span sab="792" style="font-family: Calibri;">5. How many servings of red meat, hamburger, or meat
products (ham, sausage, etc.) do you consume per day? (1 serving = 100-150
g)<span sab="793" style="mso-spacerun: yes;"> </span><b sab="794" style="mso-bidi-font-weight: normal;"><i sab="795" style="mso-bidi-font-style: normal;">Less than</i></b><i sab="796" style="mso-bidi-font-style: normal;"> <b sab="797" style="mso-bidi-font-weight: normal;">1</b></i><b sab="798" style="mso-bidi-font-weight: normal;"> </b></span></div>
</div>
</div>
<div class="MsoNormal" sab="801" style="margin: 0in 0in 10pt;">
<div sab="802">
<div sab="928">
<span sab="803" style="font-family: Calibri;">6. How many servings of butter, margarine, or cream do you
consume per day? (1 serving = 12 g)<span sab="804" style="mso-spacerun: yes;"> </span><b sab="805" style="mso-bidi-font-weight: normal;"><i sab="806" style="mso-bidi-font-style: normal;">Less
than 1 </i></b></span></div>
</div>
</div>
<div class="MsoNormal" sab="809" style="margin: 0in 0in 10pt;">
<div sab="810">
<div sab="935">
<span sab="811" style="font-family: Calibri;">7. How many sweet/carbonated beverages do you drink per
day?<span sab="812" style="mso-spacerun: yes;"> </span><b sab="813" style="mso-bidi-font-weight: normal;"><i sab="814" style="mso-bidi-font-style: normal;">Less than 1</i></b> </span></div>
</div>
</div>
<div class="MsoNormal" sab="817" style="margin: 0in 0in 10pt;">
<div sab="818">
<div sab="942">
<span sab="819" style="font-family: Calibri;">8. How much wine do you drink per week?<span sab="820" style="mso-spacerun: yes;"> </span><b sab="821" style="mso-bidi-font-weight: normal;"><i sab="822" style="mso-bidi-font-style: normal;">7 or more glasses</i> </b></span></div>
</div>
</div>
<div class="MsoNormal" sab="825" style="margin: 0in 0in 10pt;">
<div sab="826">
<div sab="949">
<span sab="827" style="font-family: Calibri;">9. How many servings of legumes do you consume per week? (1
serving = 150 g)<span sab="828" style="mso-spacerun: yes;"> </span><b sab="829" style="mso-bidi-font-weight: normal;"><i sab="830" style="mso-bidi-font-style: normal;">3 or more </i></b></span></div>
</div>
</div>
<div class="MsoNormal" sab="833" style="margin: 0in 0in 10pt;">
<div sab="834">
<div sab="956">
<span sab="835" style="font-family: Calibri;">10. How many servings of fish or shellfish do you consume
per week?<span sab="836" style="mso-spacerun: yes;"> </span>(1 serving: 100-150 g fish, or
4-5 units or 200 g shellfish)<span sab="837" style="mso-spacerun: yes;"> </span><b sab="838" style="mso-bidi-font-weight: normal;"><i sab="839" style="mso-bidi-font-style: normal;">3 or
more</i></b><i sab="840" style="mso-bidi-font-style: normal;"> </i></span></div>
</div>
</div>
<div class="MsoNormal" sab="843" style="margin: 0in 0in 10pt;">
<div sab="844">
<div sab="965">
<span sab="845" style="font-family: Calibri;">11. How many times per week do you consume commercial sweets
or pastries (not homemade), such as cakes, cookies, biscuits, or custard?<span sab="846" style="mso-spacerun: yes;"> </span><b sab="847" style="mso-bidi-font-weight: normal;"><i sab="848" style="mso-bidi-font-style: normal;">Less than 3</i></b><i sab="849" style="mso-bidi-font-style: normal;"> </i></span></div>
</div>
</div>
<div class="MsoNormal" sab="852" style="margin: 0in 0in 10pt;">
<div sab="853">
<div sab="973">
<span sab="854" style="font-family: Calibri;">12. How many servings of nuts (including peanuts) do you
consume per week? (1 serving = 30 g)<span sab="855" style="mso-spacerun: yes;"> </span><b sab="856" style="mso-bidi-font-weight: normal;"><i sab="857" style="mso-bidi-font-style: normal;">3 or
more</i> </b></span></div>
</div>
</div>
<div class="MsoNormal" sab="860" style="margin: 0in 0in 10pt;">
<div sab="861">
<div sab="980">
<span sab="862" style="font-family: Calibri;">13. Do you preferentially consume chicken, turkey or rabbit
meat instead of veal, pork, hamburger or sausage?<span sab="863" style="mso-spacerun: yes;"> </span><b sab="864" style="mso-bidi-font-weight: normal;"><i sab="865" style="mso-bidi-font-style: normal;">Yes </i></b></span></div>
</div>
</div>
<div class="MsoNormal" sab="869" style="margin: 0in 0in 10pt;">
<div sab="870">
<div sab="987">
<span sab="871" style="font-family: Calibri;">14. How many times per week do you consume vegetables,
pasta, rice, or other dishes seasoned with sofrito (sauce made with tomato and
onion, leek, or garlic, simmered with olive oil<i sab="872" style="mso-bidi-font-style: normal;">)?<span sab="873" style="mso-spacerun: yes;"> </span><b sab="874" style="mso-bidi-font-weight: normal;">2 or more</b></i></span></div>
</div>
</div>
<div class="MsoNormal" sab="877" style="margin: 0in 0in 10pt;">
<div sab="878">
<div sab="994">
<i sab="879" style="mso-bidi-font-style: normal;"><span sab="880" style="font-size: 10pt; line-height: 115%;"><span sab="881" style="font-family: Calibri;">*From Table in S1 in Supplement to:
<a href="http://www.nejm.org/action/showSupplements?doi=10.1056%2FNEJMoa1200303&viewType=Popup&viewClass=Suppl" sab="882">Estruch R, Ros E, Salas-Salvadó J, et al. Primary prevention of cardiovasculardisease with a Mediterranean diet. N Engl J Med 2013.</a> </span></span></i></div>
</div>
</div>
<div class="MsoNormal" sab="884" style="margin: 0in 0in 10pt;">
<div sab="885">
<div sab="1001">
<span sab="886" style="font-family: Calibri;">Taking a closer look at the details of the study as
described in the NEJM supplement, it seems to me that the particular factors of
those listed above that really differentiated the Mediterranean groups from the
control group were: the quantity of olive oil ingested, the increase in nuts
consumed, and, somewhat less significantly, the amount of seafood consumed,
legumes consumed, and sofrito sauce consumed. </span></div>
</div>
</div>
<div class="MsoNormal" sab="887" style="margin: 0in 0in 10pt;">
<div sab="888">
<div sab="1005">
<span sab="889" style="font-family: Calibri;">In this study the particular kinds of nuts prescribed were
walnuts, hazelnuts and almonds. However, there may be health benefits with
other nuts as well. Here is some useful <a href="http://www.med.umich.edu/pfans/docs/tip-2011/healthynuts-0211.pdf" sab="890">nutritional information</a> from University
of Michigan Health System (my alma mater) about nuts. </span></div>
</div>
</div>
<div class="MsoNormal" sab="892" style="margin: 0in 0in 10pt;">
<div sab="893">
<div sab="1010">
<span sab="894" style="font-family: Calibri;">Personally, this study has changed my health practices. While
I was already doing well with some of its components, since reading the
specifics of the Mediterranean Diet prescribed and found to be associated with reduced cardiovascular risk I’ve made greater attempts to incorporate
legumes, nuts, and fish into my diet.<o:p sab="895"></o:p></span></div>
</div>
</div>
<div sab="896">
<div sab="1014">
<br /></div>
</div>
<div class="MsoNormal" sab="897" style="margin: 0in 0in 10pt;">
<div sab="898">
<div sab="1017">
<o:p sab="899"><span sab="900" style="font-family: Calibri;"> </span></o:p></div>
</div>
</div>
<div sab="901">
<div sab="1021">
<br /></div>
</div>
<div class="MsoNormal" sab="902" style="margin: 0in 0in 10pt;">
<div sab="903">
<div sab="1024">
<o:p sab="904"><span sab="905" style="font-family: Calibri;"> </span></o:p></div>
</div>
</div>
</div>
<div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com0tag:blogger.com,1999:blog-3946741689271235070.post-36463729752675010772013-06-11T17:30:00.001-07:002013-06-11T17:30:17.894-07:00Alternative, Holistic and Integrative Medicine: Definitions and Safety Considerations<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-family: Calibri;"></span><br />
<span style="clear: left; float: left; font-family: Calibri; margin-bottom: 1em; margin-right: 1em;"><img height="200" sab="1" src="http://www.google.com/url?sa=i&source=images&cd=&docid=kGcz8wZbrkcKiM&tbnid=xUT68t972jQ7-M:&ved=0CAUQjBwwAA&url=http%3A%2F%2Fwww.greatjakes.com%2Fblog%2Fwp-content%2Fuploads%2F2011%2F04%2Fsnake-oil.jpg&ei=_763UdONFYW09gTYwIGgBA&psig=AFQjCNHmaOR0B7rf-L7qxdXFjKNVx9TpcA&ust=1371082879386845" width="168" /></span><br />
<span style="font-family: Calibri;">Recently a patient of mine brought in a bottle given to her
by her acupuncturist. She had turned to acupuncture with my encouragement after
traditional medicine fell short at addressing her chronic pain.
Indeed, there is data to support the <a href="http://nccam.nih.gov/research/results/spotlight/091012">efficacy of acupuncture</a> in the management
of chronic pain </span><span style="font-family: Calibri;">.
I was encouraged to hear that this treatment, often labeled as “alternative,”
seemed to be helping her substantially.<span style="mso-spacerun: yes;"> </span></span><br />
<span style="font-family: Calibri;"><span style="mso-spacerun: yes;"></span></span><br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">However, my patient’s questions had to do with the
ingredients of the herbal medication she was given to help
with weight loss and phlegm-- a potpourri of botanicals translated from Chinese
to English. She asked for my assessment and blessing, reminding me that I was a
self-proclaimed “holistic” doctor. Quickly I scanned the product’s label. It contained,
among other things, Raphanus Semen, something I immediately felt that I
personally would not care to ingest. Despite my initial concern, I promised to
research the herbal supplement to the best of my ability.<span style="mso-spacerun: yes;"> </span>Later, I discovered that Raphanus Semen was
radish seed, which at least seemed less disgusting than what I had imagined. </span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">This patient interaction brought to light two topics worth
discussing: </span></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0in 0in 0pt 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="font-family: Calibri;">1.</span><span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: Calibri;">What is meant by “Holistic Medicine?” <o:p></o:p></span></div>
<br />
<div class="MsoListParagraphCxSpLast" style="margin: 0in 0in 10pt 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="font-family: Calibri;">2.</span><span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: Calibri;">How does one assess the safety of complementary
and alternative therapy, and more specifically, of botanicals and natural
supplements?</span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">I am fairly certain that “<strong>holistic</strong>” does not carry the same meaning
to me as it does to many Americans.<span style="mso-spacerun: yes;"> </span>In
my view holism in medicine implies having a whole person view.<span style="mso-spacerun: yes;"> </span>That is, seeing each patient, not just as a
constellation of physical symptoms to diagnose and treat, but also within their
psychosocial context.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>After all, a person’s unique psychology and cultural
background determine how he or she reacts to physical illness,
diagnosis, medical advice, and treatment prescribed.<span style="mso-spacerun: yes;"> </span>A doctor who makes attempt to understand
these parts of his or her patients is apt to be more successful at treating them.
However, most Americans tend to think of a “holistic doctor” as one who is well-versed in alternative therapies and who bucks standardized approaches endorsed
by the medical establishment, including the pharmaceutical industry and the FDA.
<span style="mso-spacerun: yes;"> </span>This is not true of my practice, though
I am aware of the existence of bias and limitation within the scientific process. </span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">As of late, the term “<strong>Holistic Medicine</strong>” has actually become
antiquated and has been replaced by the contemporary field of “<strong>Integrative Medicine</strong>.”
As defined by the wise <a href="http://www.drweil.com/drw/u/ART02054/Andrew-Weil-Integrative-Medicine.html">Dr. Andrew Weil</a>, one of its best known proponents:</span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<b><span style="color: black; font-family: "Arial","sans-serif"; font-size: 9pt; line-height: 115%;">“</span></b><span style="font-family: Calibri;"><b><span style="color: black; mso-bidi-font-family: Arial;">Integrative Medicine</span></b><span style="color: black; mso-bidi-font-family: Arial;"> is healing-oriented medicine that takes account of the
whole person (body, mind, and spirit), including all aspects of lifestyle. It
emphasizes the therapeutic relationship and makes use of all appropriate
therapies, both conventional and alternative</span></span><span style="color: black; font-family: "Arial","sans-serif"; font-size: 9pt; line-height: 115%;">.”</span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="color: black; mso-bidi-font-family: Arial;"><span style="font-family: Calibri;">By this
description I am an advocate of Integrative Medicine, though, the key point
here is “use of all appropriate therapies.”<span style="mso-spacerun: yes;">
</span>The unfortunate truth is that many physicians who profess to practice
Integrative Medicine treat multiple diagnoses that are not <em>at all</em> well-established
by science, for example, “adrenal fatigue.” In addition, many advocate use of products that
lack sufficient evidence for safety and efficacy, for example DHEA or bio-identical hormones, and disavow standard FDA approved drugs for unclear reasons.<span style="mso-spacerun: yes;"> </span>This business too can be a money-making operation, as some
of these physicians do not bill health insurance for their services, run a
multitude of diagnostic lab tests of uncertain significance, and may even sell
their non-approved “natural” products for significant profit. </span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt; text-align: left;">
<span style="font-family: Calibri;">Which complementary and alternative therapies are safe and
reasonable to try? There are a number of resources that can help to guide both
doctors and patients, such as NIH’s National Center for Complementary and
Alternative Therapy page on <a href="http://nccam.nih.gov/health/herbsataglance.htm">Herbs at a Glance</a>. </span><span style="font-family: Calibri;">Unlike prescription drugs, the manufacturers of
medicinal herbs and botanicals are not required to prove the safety and
efficacy of their products prior to marketing them.<span style="mso-spacerun: yes;"> </span>In addition to the definite possibility that
these substances might be ineffective, there are two major safety
considerations--their potential for causing drug interactions and the risk of product contamination. If you are researching for negative reports on a particular substance you may find the NIH's index "<a href="http://nccam.nih.gov/health/safety/topics.htm">How Safe is this Product or Practice?</a>" to be useful. </span><span style="font-family: "Helvetica","sans-serif"; font-size: 10pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"> </span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">In the case of my patient, she is on a fairly long list of
medications for several serious health conditions.<span style="mso-spacerun: yes;"> </span>For example, she has a history of pulmonary
embolus and also has an inherited condition that makes her prone to clotting. For
this she takes a blood thinner. Her other drugs include strong pain medications
and several psychotropic drugs with narrow therapeutic indices. My immediate
concern was for the possibility of botanical-drug interactions, which might
increase or decrease levels of her prescription drugs and cause toxicity
or adverse medical events.</span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">It turns out that my research was unable to shed light on any
reliable information whatsoever about Raphanus Semen, nor the remaining six
ingredients of the herbal medication that she showed me. I was left to shrug my
shoulders and advise her, in this case, “probably not a good idea.” <span style="mso-spacerun: yes;"> </span>On the other hand, I support the use of acupuncture
for chronic pain and have been known to advise melatonin for sleep, probiotics
for various digestive ails, and even strontium for osteoporosis.<o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-size: 10pt; line-height: 115%;"><o:p><span style="font-family: Calibri;"> </span></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-size: 10pt; line-height: 115%;"><o:p><span style="font-family: Calibri;"> </span></o:p></span></div>
</div>
<div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com1tag:blogger.com,1999:blog-3946741689271235070.post-11951722916834732492013-03-25T16:17:00.001-07:002013-03-25T16:17:28.692-07:00Have you planned your retirement from driving?<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgFRMc_8CiXeDCNnuaSOudgDVpxfwjkqVPE_yyKa5pBDpr8Q-Z3uULeYMueXxasz0GcA7RBbkgfNQytnJgOsbsbEeaJstrwqt8bZq6xSU0ioMfnOzxkzQwDuwagjQtG1gQgyDJQD2KfvQcb/s1600/IMG_0860.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgFRMc_8CiXeDCNnuaSOudgDVpxfwjkqVPE_yyKa5pBDpr8Q-Z3uULeYMueXxasz0GcA7RBbkgfNQytnJgOsbsbEeaJstrwqt8bZq6xSU0ioMfnOzxkzQwDuwagjQtG1gQgyDJQD2KfvQcb/s320/IMG_0860.JPG" width="320" /></a></div>
<span style="font-family: Calibri;">When should drivers retire from driving? This question is
always difficult to answer. <span style="mso-spacerun: yes;"> </span>In our suburban
car culture driving allows seniors to maintain their independence and
prevents social isolation. However, at what point does it become unsafe for the
elderly to drive and what are the risks?</span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">One month ago my fit and about 80-year-old in-laws were
involved in a serious car accident. A young man crashed into the passenger side
back corner of their car on the highway as he shifted from right to left lane
behind them causing them to lose control, and sending them head on into the concrete
median of the highway.<span style="mso-spacerun: yes;"> </span>He drove away, his car and him unscathed, but my in-laws were not so lucky.<span style="mso-spacerun: yes;"> </span>Their car was totaled and they were taken to
Grady Hospital in Atlanta. My father-in-law, who suffered a lumbar fracture and
contusions, was released after three days. My mother-in-law had more serious
injuries—she fractured all of her ribs on the left, her sternum, and subluxed
her cervical spine to a dangerous degree requiring emergent decompression and
fusion or the cervical spine to prevent spinal cord injury. She stayed in the
hospital for one week, and then came to our home to convalesce for another
three weeks, requiring physical therapy, home oxygen, a home health aide and
multiple assistive devices to help with her activities of daily living.
Fortunately, she has done very well, and recently has flown home to Michigan where
she will continue to do physical therapy to try to regain her former functional
ability, which was fantastic (just before the accident she was giving dinner
parties and had planted pansies in my back yard).<span style="mso-spacerun: yes;"> </span>My father in law was also in great shape—an avid
gardener and retired physician. He maintains his medical license and stays
current by reading the New England Journal of Medicine. </span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">It would never have occurred to
me to caution my in-laws not to drive, either as a physician or as a concerned family
member, given their excellent physical and cognitive functioning.<span style="mso-spacerun: yes;"> However, the accident did cause me to reflect upon the issue of driving and safety for seniors. There are two components of driving risk for the elderly:<span style="mso-spacerun: yes;"> </span>the risk that a senior driver could present to another person on the road, and that which an elderly driver poses to his or herself. </span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">It turns out that with the aging process, changes
in the architecture and mechanics of bones makes them more prone to fracture.
Not only are bones more osteoporotic, but also the rib cage changes shape
making it more susceptible to injury by frontal force.<span style="mso-spacerun: yes;"> </span>Loss of muscle mass and subcutaneous fat
increase the likelihood of serious injury. <span style="mso-spacerun: yes;"> </span>My mother-in-law, the front passenger,
restrained by a seat belt and cushioned by the airbag of her Hyundai Sonata,
certainly was a victim of these physiological changes. </span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">According to the <a href="http://www.nhtsa.gov/Driving+Safety/Older+Drivers">National Highway Traffic SafetyAdministration</a> the elderly (persons 65 and older) make up 16% of traffic
fatalities.<span style="mso-spacerun: yes;"> </span></span><span style="font-family: Calibri;">
As we all know the elderly are a growing percent of our population. What will
happen to travel patterns as our population ages?<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><a href="http://www.aarp.org/research/ppi/liv-com2/policy/transportation/articles/impact-of-baby-boomers-on-us-travel-1969-2009-AARP-ppi-liv-com.html">A study by the AARP</a> in 2012 looked at the impact of the baby
boom on travel and recommended research into strategies aimed to address the
specific transportation needs of the senior population. </span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><span lang="EN" style="mso-ansi-language: EN;">Debra Whitman,
AARP Executive Vice President for Policy, quoted in the <a href="http://www.huffingtonpost.com/2012/11/09/elderly-driving-aarp-study_n_2100830.html">Huffington Post</a> report
on this study, said: “people who live past age 70 will outlive their driving
years by seven to 10 years on average. The challenge will come when the
generation that is turning the suburbs gray hangs up the keys.”</span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Often family members come to physicians asking for help with
telling their loved one not to drive. I remember one patient who was 90
and had dementia and severe cardiovascular disease. I recommended to his family
that he quit driving after he had several fender benders in town. However, I
would have liked for him to stop before the fender benders. There are a variety
of resources on line to help guide seniors and their family members on decision
making about driving in the elderly. <span style="mso-spacerun: yes;"> In the case of my in-laws my feeling is that they, and many other octogenarians in similar shape should safely be able to drive. However, given their increased risk of serious injury, perhaps car design needs to evolve to better meet the safety needs of the elderly driver and passenger. </span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">What is your plan for driving and transportation as you grow
older? Have you given it thought? Are you confident that you will know when it’s
time to turn over the keys? Just as middle-aged adults think about retirement, long-term
care insurance, estate planning and advanced directives, they should also think
about their plan for transportation as they grow older.<span style="mso-spacerun: yes;"> In turn there is a social need to address how to maintain safe and efficient transportation for our seniors, which enables our healthy octogenarians to maintain independent living for as long as possible.</span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Here are some helpful resources:</span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><a href="http://www.nia.nih.gov/health/publication/older-drivers">Older Drivers</a> (National Institute on Aging) </span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><a href="http://seniordriving.aaa.com/">Senior Driving</a> (AAA) </span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><a href="http://www.google.com/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=3&cad=rja&sqi=2&ved=0CEQQFjAC&url=http%3A%2F%2Fwww.ama-assn.org%2Fama1%2Fpub%2Fupload%2Fmm%2F433%2Folder-drivers-appendixb.pdf&ei=i8tNUeSuFYTs8wT2goCIBw&usg=AFQjCNHrCA3mueLugAousgCzH_oPrKydcA&sig2=4oE_crlESbdm9Sda7lga6w">Patient and Caregiver Educational Materials</a> (AMA)</span></div>
<span style="font-family: Calibri;"><a href="http://www.blogger.com/)%20http://www.ama-assn.org/ama/pub/physician-resources/public-health/promoting-healthy-lifestyles/geriatric-health/older-driver-safety/assessing-counseling-older-drivers.page">Physician’s Guide to Assessing and Counseling Older Drivers</a> (AMA)</span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><o:p></o:p></span> </div>
</div>
<div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com2tag:blogger.com,1999:blog-3946741689271235070.post-72651019520547707412013-02-05T13:52:00.000-08:002013-03-23T12:35:32.667-07:00Generic Drugs: Bioequivalent and Interchangeable?<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhx9A-CcqvkvVqDgZBogxfO2SlEcLatJZpdEROlM9I0zQ0Hu-Uz8WltDPi_wr8fXPP_RLzzQsOxv073dHw8X6IuRaBXXLaj9xBhIWcjNwSXpM-ZddXysLwc4abOoALHB0QFiJDRMY_92Os9/s1600/plavix+and+clopidogrel.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhx9A-CcqvkvVqDgZBogxfO2SlEcLatJZpdEROlM9I0zQ0Hu-Uz8WltDPi_wr8fXPP_RLzzQsOxv073dHw8X6IuRaBXXLaj9xBhIWcjNwSXpM-ZddXysLwc4abOoALHB0QFiJDRMY_92Os9/s1600/plavix+and+clopidogrel.jpg" /></a></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Use of generic drugs has the potential to reduce annual </span><a href="http://online.wsj.com/article/SB10001424127887323751104578147451523199938.html"><span style="color: blue; font-family: Calibri;">consumer spending on prescriptions</span></a><span style="font-family: Calibri;"> by billions. A study published in the </span><a href="http://www.nejm.org/doi/full/10.1056/NEJMsa1104816#t=article"><span style="color: blue; font-family: Calibri;">New England
Journal of Medicine</span></a><span style="font-family: Calibri;"> and discussed in the </span><a href="http://economix.blogs.nytimes.com/2012/06/04/cheap-vs-expensive-drugs/"><span style="color: blue; font-family: Calibri;">New
York Times Economix</span></a><span style="font-family: Calibri;"> blog in 2012 looked at Medicare Part D expenditures and
correlated them with drug prescribing patterns. The regions of the United
States with the highest Medicare expenditures were those where more name brand
drugs were prescribed.<span style="mso-spacerun: yes;"> But, are generic drugs as safe and effective as name brand drugs? </span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Generic medications become available after brand name drugs
go off patent (usually 10 to 14 years after coming to market). The
pharmaceutical industry maintains that the high cost of brand name drugs
relates to the research and development required to innovate and bring new
products to market.<span style="mso-spacerun: yes;"> </span>Advertising and
promotion are also, no doubt, a major factor.<span style="mso-spacerun: yes;">
</span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">A generic drug is a drug that has been determined to be the <b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;">bioequivalent</i></b>
of a brand name drug in terms of its active ingredient.<span style="mso-spacerun: yes;"> </span>Standards for proving bioequivalence are
defined by the FDA and are similar to standards used in Canada, Japan and
Europe.<span style="mso-spacerun: yes;"> </span>Here’s what the </span><a href="http://www.fda.gov/Drugs/EmergencyPreparedness/BioterrorismandDrugPreparedness/ucm134444.htm"><span style="color: blue; font-family: Calibri;">FDA
website</span></a><span style="font-family: Calibri;"> says about bioequivalence:<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">“One way scientists demonstrate bioequivalence is to measure
the time it takes the generic drug to reach the bloodstream and its concentration
in the bloodstream in 24 to 36 healthy, normal volunteers. This gives them the
rate and extent of absorption-or bioavailability-of the generic drug, which
they then compare to that of the pioneer drug. The generic version must deliver
the same amount of active ingredients into a patient's bloodstream in the same
amount of time as the pioneer drug.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">The following </span><a href="http://www.bpac.org.nz/magazine/2007/march/bioequiv.asp"><span style="color: blue; font-family: Calibri;">graph</span></a><span style="font-family: Calibri;"> illustrates
the bioavailability of two drugs, Drug A and Drug B. The statistics may be
difficult to understand, but to be determined <i style="mso-bidi-font-style: normal;">bioequivalent</i> the 90% confidence interval of the ratios of the mean
bioavailability, or “area under the curve” (AUC), of the two drugs and their
peak concentrations (Cmax) must be in the ranges of 80 to 125%.<span style="mso-spacerun: yes;"> </span>In more concrete terms, analyses of numerous
studies of bioequivalence have shown that differences in blood concentrations
of the active ingredients of branded versus generic drugs are generally less
than 4 percent.<o:p></o:p></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhq99u2FxForI180iMJbFwEKOSqoiIicih1VEohUZKbDQgtlyhcuwD9Zn2H-gWVTKmLzCfykh-5I3uaat4k1dz6L_4dEmvPtZQ3f3r4HmJ4IWB9-WUzU_FfA222An1hZmhdDD-LA-2jbSMv/s1600/drug_levels_graph.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="230" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhq99u2FxForI180iMJbFwEKOSqoiIicih1VEohUZKbDQgtlyhcuwD9Zn2H-gWVTKmLzCfykh-5I3uaat4k1dz6L_4dEmvPtZQ3f3r4HmJ4IWB9-WUzU_FfA222An1hZmhdDD-LA-2jbSMv/s320/drug_levels_graph.gif" width="320" /></a></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Once a generic drug is deemed to be bioequivalent by these </span><a href="http://www.sciencebasedmedicine.org/index.php/generic-drugs-are-they-equivalent/"><span style="color: blue; font-family: Calibri;">statistical
standards</span></a><span style="font-family: Calibri;"> it is not required to go through the same extensive clinical
safety and efficacy trials, as a newly innovated brand name drug applying for its
initial patent.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">What are some pitfalls of using generics? The inactive
ingredients in generics compared with branded drugs are not required to be the
same. Therefore allergies to these fillers and inactive compounds can be an
issue. Also, special consideration should be taken when changing from a branded
drug to a generic drug, or when changing between generics, if the drug has a <b style="mso-bidi-font-weight: normal;">narrow therapeutic index</b>. Some drugs
with narrow therapeutic indices include thyroid medications, anti-epileptics
and warfarin.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Here are some examples of issues that come up with generics:<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">The adhesive contained in a fentanyl transdermal patch
differs depending on whether the patch is generic or brand name. Some of my
patients have developed allergies to the adhesive in the brand name patch (as
opposed to the generic,) others complain that the generics don’t stick as well.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Along the lines of narrow therapeutic index—I can recall two
separate instances in which a patient was changed to a new warfarin generic drug
product. In each case the patient’s PT and INR (coagulation test) had been
stable for months, but after the change their levels of anti-coagulation became
too high. This took some detailed history-taking to figure out. One </span><a href="http://www.medscape.com/viewarticle/740268_1"><span style="color: blue; font-family: Calibri;">review of the literature</span></a><span style="font-family: Calibri;">
suggested that generic warfarin and Coumadin products are equally effective and
safe and uphold the FDA’s criteria for bioequivalence, yet the authors still
suggested that patients limit switches amongst warfarin products and brand and monitor
anti-coagulation after making changes. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">If a product is deemed bioequivalent then it is also deemed “interchangeable”
and </span><a href="http://aspe.hhs.gov/sp/reports/2010/genericdrugs/ib.shtml#apa"><span style="color: blue; font-family: Calibri;">pharmacists
are not required to inform physicians</span></a><span style="font-family: Calibri;"> when they change a patient from brand
to generic, or when they change from one generic to another.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Another patient, who reports a high level of drug
sensitivity, noticed that a particular generic of nortriptyline used for
chronic insomnia was more effective for him than others. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Thyroid medication is known to vary amongst the generics and
Synthroid brand in terms of clinical effects. While the FDA has deemed these
various products to be bioequivalent and interchangeable many endocrinologists
disagree. <span style="mso-spacerun: yes;"> </span>In attempt to address this
issue in 2004 a </span><a href="http://www.endo-society.org/advocacy/legislative/upload/Joint_Statement_Levothyroxine-Thyroxine.pdf"><span style="color: blue;"><span style="font-family: Calibri;"><span style="mso-spacerun: yes;"> </span>Joint Statement</span></span></a><span style="font-family: Calibri;"> was issued by the major
endocrinology professional societies making recommendations on the topic. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">The most </span><a href="http://www.washingtonpolicy.org/publications/brief/biosimilars-precarious-struggle-between-cost-driven-health-care-policy-and-patien"><span style="color: blue; font-family: Calibri;">recent
controversy</span></a><span style="font-family: Calibri;"> regarding generics has to do with biological drugs, or
“biologics.” Because of the inherent complexity of these innovator drugs, which
are derived from living cells, the concept of “biosimilar” has replaced
bioequivalent for the generic products being developed.<span style="mso-spacerun: yes;"> </span>As reported last week in the </span><a href="http://www.nytimes.com/2013/01/29/business/battle-in-states-on-generic-copies-of-biotech-drugs.html"><span style="color: blue; font-family: Calibri;">New
York Times</span></a><span style="font-family: Calibri;">, the pharmaceutical industry is currently engaged intense
lobbying to prevent biosimilar generic biologics from coming to market as
competition to the numerous, ultra-expensive biologics whose patents will be
expiring in the near future.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">The science behind the FDA approval process for generic drugs
is rigorous. My advice, it can be smart to try a generic. There is no evidence
that these products are of lower quality, or less effective than name brand
products—though they are not required to go through clinical efficacy trials.
However, be wary of minor fluctuations in the clinical effects of your medications
when switching between name brand and generic, and amongst different generics,
and be aware that your pharmacist may change your generic from one manufacturer
to another without your knowledge (the pill should look different).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">What is your experience with generic medications versus name
brand products? <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
</div>
<div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com1tag:blogger.com,1999:blog-3946741689271235070.post-5351078330623748552013-01-21T16:29:00.000-08:002013-01-23T16:33:42.379-08:00A Lesson on Mental Illness Care: Connecting Two Tragedies<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="http://www.csmonitor.com/var/ezflow_site/storage/images/media/content/2012/1226_us_newtown/14617257-1-eng-US/1226_US_Newtown_full_600.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="213" src="http://www.csmonitor.com/var/ezflow_site/storage/images/media/content/2012/1226_us_newtown/14617257-1-eng-US/1226_US_Newtown_full_600.jpg" width="320" /></a></div>
<span style="font-family: Calibri;">For the past month I’ve been trying to formulate a blog that could capture my thoughts about mental illness and the prevention of violence. At this point my ideas are still not crystallized, but perhaps writing this will help. A few days before Christmas I received a phone call from a former patient’s mother. <span style="mso-spacerun: yes;"> </span>She called while I was at the mall with my family doing some last minute shopping—I had taken the day off work.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>My patient, who I will call “Mark,” and his family had left the state of Georgia and my care approximately 6 months prior.<span style="mso-spacerun: yes;"> </span>Fighting to contain her grief Mark’s mother told me that her son, who was just 25 years old, had taken his own life.<o:p></o:p></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">It came as a shock, though admittedly during the brief time that I doctored Mark I had been very concerned about his well-being. <span style="mso-spacerun: yes;"> </span>His mother said that she wanted me to know because I had worked so hard to help her son. As I listened to the story of the months leading up to his suicide I was flooded with questions:<span style="mso-spacerun: yes;"> </span>Could I have prevented this? How did he kill himself? Had he found another physician after he moved? Had he been seeing a psychiatrist, as I had recommended? </span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">I had only cared for Mark for three or four months. When we first met, early in 2012, his mother and he were desperate.<span style="mso-spacerun: yes;"> </span>She called me one evening after clinic hours. I was at my son’s saxophone lesson and stepped outside to take the call. She found my medical practice and phone number on Google. She thought I might be able to help. He’d had a tough childhood. His sister was severely disabled. Then, he suffered a traumatic life event in college. Mark, though obviously very intelligent, had dropped out, unable to function. <span style="mso-spacerun: yes;"> </span>While he was my patient Mark confided that he was desperate to be independent and get back to normal functioning, but felt crippled by his health.<span style="mso-spacerun: yes;"> </span>He was a very likable young man who I connected with.</span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">He described multiple symptoms—head pressure, mental fogginess, intense pain and burning all over his body coursing from his center outward and down his extremities, nausea, heartburn, post-nasal drip, an intensely dry mouth, insatiable thirst, difficulty swallowing, loss of appetite, change in his bowel habits, weight loss and muscle wasting.<span style="mso-spacerun: yes;"> </span>Mark felt that he was dying from a medical condition that remained undiagnosed. As he explained it, his trouble had started while was under the care of a psychiatrist. He attributed some of his symptoms to a medication, a serotonin re-uptake inhibitor, Effexor, which he felt had permanently changed him. </span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">He asked if I could test him for permanent damage caused by traces of the drug that might remain in his blood stream months after his last dose. He had left his psychiatrist’s care wanting another opinion and a thorough evaluation of these physical symptoms that were relentless and incapacitating. <span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">I embarked on a very thorough medical evaluation—including a plethora of blood tests, an MRI of his brain, a neurology and an allergy and immunology consultation.<span style="mso-spacerun: yes;"> </span>I knew all the while that the root problem was very likely his underlying psychiatric condition. Mark acknowledged ongoing depressed mood and severe long-standing anxiety, but was primarily concerned about his physical health. I asked to speak with his psychiatrist, but his preference was that I evaluate his condition independently, and he refused. <span style="mso-spacerun: yes;"> </span>When questioned about thoughts of self-harm or harming others Mark stated, “I could never do that to my mother.”<o:p></o:p></span></div>
<span style="font-family: Calibri;">After frequent lengthy office visits and phone calls over a period of several months I was not able to arrive at a unifying medical diagnosis that explained my patient’s condition. I was, however, increasingly concerned about his psychological health and referred him to another psychiatrist. I had become aware of underlying paranoid overtones in his affect, which I felt were delusional. He had been concerned about a pharmacy contaminating his prescriptions with a substance that made him ill. He asked me if I knew what the substance was (I had never heard of it), and asked me to investigate it. He expressed suspicion about various commercial labs and preferred that I send his lab specimens to a smaller lab that he had researched and chosen. He felt this lab would do a more accurate job with his lab testing. He asked me my opinion on his future career—he said he was very interested in the military, and asked if I thought that might be a good direction for him.<span style="mso-spacerun: yes;"> </span>Inwardly I cringed at the thought, and tried to steer him toward a more flexible career choice, and one that would not involve use of firearms. <o:p></o:p></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">After several months of working closely with Mark his mother informed me that the family would be moving out of state.<span style="mso-spacerun: yes;"> </span>Although the timing was not ideal, his father could not turn down the job opportunity and Mark could not stay on his own. Despite my referrals he had never established with a new psychiatrist.<span style="mso-spacerun: yes;"> </span>In a last ditch attempt to get him some help, I made a phone call to a psychiatrist who I knew and trusted. The psychiatrist agreed to see Mark several times prior to his move—it was the best we could think of. </span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><span style="mso-spacerun: yes;"> </span>I felt that I needed to clearly articulate my clinical impression to Mark’s mother prior to their departure, which was that my patient was suffering from a psychiatric condition that caused a disorder of thinking in the form of paranoia and delusions.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>I mentioned schizophrenia. Mark’s mother acknowledged that this diagnosis had been previously suggested, but that she and Mark wanted another opinion.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">At the time of his last visit Mark brought in a fairly organized list of the symptoms he was suffering from and how they impacted his ability to function. He wanted me to write a letter attesting to the fact that he was unable to work or go to school because of his condition. I agreed to write a letter describing his condition, which was difficult given the fact that there was no psychiatrist involved and his diagnosis appeared to be primarily psychiatric—I explained this to Mark and had a direct conversation with him about my clinical impression. </span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">The visits to my psychiatrist referral never occurred. My patient moved later that summer and I had no further contact until the phone call in December. The news about my patient’s tragic suicide came one week after the shooting at Newtown, where, as we all know, another young man with significant psychiatric illness inexplicably sacrificed not only his life, but the lives of 26 children and teachers. I immediately wondered if my patient had shot himself, but somehow during our brief phone conversation, I could not bring myself to ask his mom how he died—it seemed irrelevant to her grief at the time. These two events cast a shadow over my holiday season.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<div class="separator" style="clear: both; text-align: center;">
</div>
<span style="font-family: Calibri;">I continue to try to make reason of these two tragedies, hoping to arrive at a pithy lesson by connecting the two that I can bring to clinical practice to avoid future heartbreak. What makes it so difficult to get patients with psychiatric illness the help that they need? In this case it was not problems of access, but the underlying disease process itself made my patient resistant to care. <span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><span style="mso-spacerun: yes;"> </span>I am still searching for broader answers, but perhaps I will start with a call back to my patient’s mother to find out more details. In the meantime, I remain highly skeptical that improved mental health care alone, without restricting access to firearms will be enough to curb gun violence in our country.<o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
</div>
<div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com0tag:blogger.com,1999:blog-3946741689271235070.post-15552678274604057422012-12-09T06:10:00.000-08:002012-12-09T06:10:04.523-08:00Preventing Shingles<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg1YcDnth_xsX_Q0H4Ykk462aHNiRaWowAQS1M9dayMD9h5oei_7_h32Us6QypoBU6hrzbMf5dHbUG9MUU36Ft-NF51Puu8DmdIA5n1XRPL75p8Ih1TPwPU7Gxs3hCchsVrXfYlp25EidXA/s1600/shingles+body.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg1YcDnth_xsX_Q0H4Ykk462aHNiRaWowAQS1M9dayMD9h5oei_7_h32Us6QypoBU6hrzbMf5dHbUG9MUU36Ft-NF51Puu8DmdIA5n1XRPL75p8Ih1TPwPU7Gxs3hCchsVrXfYlp25EidXA/s1600/shingles+body.jpg" /></a></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Shingles is a common disorder.<span style="mso-spacerun: yes;"> </span>It’s caused by the reactivation of the
chicken pox virus, varicella zoster virus, which remains dormant in one’s
nerves after infection with chicken pox. Anyone who has had chicken pox is at
risk.<span style="mso-spacerun: yes;"> </span>Shingles is an unpleasant
illness.<span style="mso-spacerun: yes;"> </span>It causes prodromal nerve
irritation, followed by the appearance of a blistering rash that follows the
distribution of a nerve root. The rash can be painful and itchy, and can be the
source of subsequent bacterial infection.<span style="mso-spacerun: yes;">
</span>In some cases, cranial nerves, including nerves that supply the eye and
ear, may be affected and this may lead to loss of vision or hearing. </span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">The most
unpleasant complication of shingles is the occurrence of “post-herpetic
neuralgia,” defined as pain in the distribution of the shingles rash (or
affected nerve root), which persists for more than three months after the shingles
goes away--this may occur in 10 to 20% of cases.<span style="mso-spacerun: yes;"> </span>Early treatment with antiviral therapy may
reduce the risk of post-herpetic neuralgia.</span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">One’s risk of developing shingles, and post-herpetic
neuralgia as a complication, increases with age.<span style="mso-spacerun: yes;"> </span>Immune deficiency, such as infection with HIV/AIDS
or treatment with cancer chemotherapeutic drugs, also increases one’s
susceptibility to shingles.<span style="mso-spacerun: yes;"> </span>It is uncertain
how the use of the chicken pox vaccine, now standard in children, will affect
their adult risk of shingles compared with those who are unvaccinated. <o:p></o:p></span></div>
<span style="font-family: Calibri;">A vaccine for shingles, Zostavax<span style="font-size: 9pt; mso-bidi-font-size: 10.0pt;">®</span>, was FDA approved in 2006. In 2008 the CDC
recommended that persons over the age of 60 receive the vaccine.<span style="mso-spacerun: yes;"> </span>This recommendation is based on the relatively
higher prevalence of shingles and its related complication in this age bracket.
However, the shingles vaccine is also effective in healthy adults ages
50-59.<span style="mso-spacerun: yes;"> </span>At this time the CDC has not
recommended routine vaccination of this age group, which is likely related to
lower disease incidence (about 4.6% annually in 50 year olds, compared with
7% annually in 60 years olds ,and 9 to 11% in 70 and 80 year olds). <o:p></o:p></span><br />
<span style="font-family: Calibri;"></span><br />
<span style="font-family: Calibri;">Here are some common questions that patients ask me about
the shingles vaccine:<o:p></o:p></span><br />
<br />
<div class="MsoListParagraphCxSpFirst" style="margin: 0in 0in 0pt 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="font-family: Calibri;">1.</span><span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;"><strong>If I have already had shingles should I get a
vaccine? <o:p></o:p></strong></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in;">
<span style="font-family: Calibri;">The shingles vaccine has not been tested in
those who have already had shingles once. It is speculated that having the
condition increases one’s immunity and helps prevent future recurrences. However,
there is some <a href="http://www.health.harvard.edu/newsletters/Harvard_Health_Letter/2011/March/the-shingles-vaccine">research</a> </span><span style="font-family: Calibri;">
<span style="mso-spacerun: yes;"> </span>indicating that those who have already
been afflicted may continue to be at significant risk for recurrence. Therefore,
it may be reasonable for this population to be vaccinated.<o:p></o:p></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="font-family: Calibri;">2.</span><span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;"><strong>What are the most common side effects related to
the shingles vaccine?<o:p></o:p></strong></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in;">
<span style="font-family: Calibri;">According to the <a href="http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-shingles.pdf">CDC</a>,
redness, pain, itching, and swelling at the site of the vaccine may occur in 1
out of 3 who receives the vaccine. Headache may occur in 1 out of 70.<span style="mso-spacerun: yes;"> </span>More serious allergic reactions to the
vaccine components including fever, difficulty breathing and throat swelling,
are infrequent.</span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="font-family: Calibri;">3.</span><span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;"><strong>Will it be safe for me to be around babies,
pregnant women, and those with immune compromise after I have had the shingles
vaccine?</strong><span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in;">
<span style="font-family: Calibri;">Yes, although it is a live attenuated virus
vaccine, there have been no described cases of the chicken pox virus being
transmitted in this manner from a person inoculated with Zostavax ®to a person who
is not immune.<o:p></o:p></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="font-family: Calibri;">4.</span><span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";"> <strong>
</strong></span></span></span><span style="font-family: Calibri;"><strong>In what population is the shingles vaccine
contraindicated?<o:p></o:p></strong></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in;">
<span style="font-family: Calibri;">Although shingles is more common in those with
immune compromise, the shingles vaccine is contraindicated in this population,
which includes patients with HIV/AIDS, patients on cancer chemotherapy,
patients on drugs that affect their immune system (such as oral steroids), and
pregnant women. There are case reports describing disseminated shingles resulting
from the vaccine in patients with established immune deficiency. <o:p></o:p></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="font-family: Calibri;">5.</span><span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;"><strong>I’m not sure if I had chicken pox, Should I have
a shingles vaccine?<o:p></o:p></strong></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in;">
<span style="font-family: Calibri;">Persons who are unsure of whether or not they
have had chicken pox should have blood work done to determine their immunity.
If there is no evidence of previous exposure then a chicken pox vaccine
(Varicella) should be administered in those who are eligible, not a Zostavax®.<o:p></o:p></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="font-family: Calibri;">6.</span><span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;"><strong>After 60, how often does one need a shingles
vaccine?<o:p></o:p></strong></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in;">
<span style="font-family: Calibri;">Currently a single vaccine at or after age 60 is
recommended.<span style="mso-spacerun: yes;"> </span>The shingles vaccine is also
FDA approved for patients ages 50-59 years.<span style="mso-spacerun: yes;">
</span>However, given the lower disease prevalence and risk in this population
the cost and health-benefit is not as well established and at this time the CDC
does not specifically recommend it.<span style="mso-spacerun: yes;"> </span>It
remains uncertain how long the immunity conferred by a single shingles vaccine
will last.<o:p></o:p></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="font-family: Calibri;">7.</span><span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";"> <strong>
</strong></span></span></span><span style="font-family: Calibri;"><strong>What is the cost of a shingles vaccine?<o:p></o:p></strong></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in;">
<span style="font-family: Calibri;">A shingles vaccine costs approximately
$200. Many health insurance plans, including Medicare Part D and private
insurers, cover the immunization after (but not before) age 60. <o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">For more information visit </span><a href="http://www.cdc.gov/shingles/index.html"><span style="color: blue; font-family: Calibri;">http://www.cdc.gov/shingles/index.html</span></a><span style="font-family: Calibri;">
or </span><a href="http://nihseniorhealth.gov/shingles/aboutshingles/01.html"><span style="color: blue; font-family: Calibri;">http://nihseniorhealth.gov/shingles/aboutshingles/01.html</span></a><span style="font-family: Calibri;">
.<o:p></o:p></span></div>
<br />
<div class="MsoListParagraph" style="margin: 0in 0in 10pt 0.5in;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
<br />
<div class="MsoListParagraph" style="margin: 0in 0in 10pt 0.5in;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
</div>
<div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com0tag:blogger.com,1999:blog-3946741689271235070.post-86361229670553455742012-11-11T17:48:00.000-08:002012-11-11T17:48:23.431-08:00Andropause?<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgiNINAyMNCvchy0LNtSDjIUsurjZzEi39nteD-f036_zjM28NqnehIGGawLn3dCLC0pP9YTagaaUFZk-jxz_dGRXE52teYNz6noHLZ7izwtlkIhBFsNQKM43Lx8xG8F1Drve3kCeFpMxYt/s1600/oldmen.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="228" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgiNINAyMNCvchy0LNtSDjIUsurjZzEi39nteD-f036_zjM28NqnehIGGawLn3dCLC0pP9YTagaaUFZk-jxz_dGRXE52teYNz6noHLZ7izwtlkIhBFsNQKM43Lx8xG8F1Drve3kCeFpMxYt/s320/oldmen.jpg" width="320" /></a></div>
<span style="font-family: Calibri;">Everyone has heard of menopause, but is there a male
equivalent? Two weeks ago at <a href="http://www.ppcatl.com/">Personalized Primary Care Atlanta</a> we discussed treatment of testosterone
deficiency, or so called "andropause," in an evening health talk. PPC was happy to host <a href="http://www.urology.emory.edu/faculty/hsiao_wayland.html">Dr. Wayland Hsiao</a>, Assistant Professor of Urology from Emory University </span><span style="font-family: Calibri;">
as our discussant. Dr. Hsiao pointed out that declining testosterone levels are
normal as men age and that while some men may be asymptomatic, others may
suffer with symptoms that may negatively impact quality of life. <o:p></o:p></span></div>
<div style="text-align: left;">
<span style="font-family: Calibri;">What are the symptoms of testosterone deficiency?<span style="mso-spacerun: yes;"> </span>Loss of energy, decreased strength, reduced exercise
capacity and erectile dysfunction are some. Testosterone deficiency may also contribute
to metabolic syndrome, loss of lean muscle mass, and osteoporosis.<span style="mso-spacerun: yes;"> </span>The <a href="http://www.prostatehealthnaturally.com/downloads/ADAM_Questionnaire.pdf">ADAM questionnaire</a> is a validated tool
that can help identify symptomatic men.<span style="mso-spacerun: yes;"> <em>Morley et al. Validation of a screening questionnaire for androgen deficiency in aging males. Metabolism. 2000;49(9):1239-1242.</em></span></span><span style="font-family: Calibri;">
<o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Testosterone deficiency may be diagnosed on the basis of
blood tests. Dr. Hsaio pointed out that saliva tests are not accurate.<span style="mso-spacerun: yes;"> </span>Typically total testosterone and free
testosterone levels are measured.<span style="mso-spacerun: yes;"> </span>Free
testosterone is the active version of the hormone.<span style="mso-spacerun: yes;"> </span>If levels are low and men are deemed symptomatic
treatment involves supplementation with testosterone, which is available in various
delivery systems including transdermal gels, patches and pellets (implanted
beneath the skin of the buttocks). Dr. Hsiao is of the opinion that injections
of testosterone are not as well tolerated as the other delivery methods as they
produce hormonal peaks and troughs that are associated with more adverse
effects including flushes.<span style="mso-spacerun: yes;"> </span></span><br />
<span style="font-family: Calibri;"></span><br />
<span style="font-family: Calibri;">Given the
common nature of some of the described symptoms of testosterone deficiency it
is not always clear who should be treated. One approach, for symptomatic men
who have low or borderline testosterone levels, is a three month trial of
treatment to see if symptoms improve.</span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">What is the downside of testosterone replacement? One large
clinical trial reported in the <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1000485">New England Journal of Medicine</a> in 2010 </span><span style="font-family: Calibri;">
demonstrated increased cardiovascular events in men who were randomized to
treatment, and the trial was terminated early because of these adverse outcomes. However,
Dr. Hsiao is skeptical that these risks translate to all men, and he
noted that the population studied was primarily elderly, frail, and immobile. </span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Another concern with testosterone therapy is whether it has potential to promote prostate cancer growth in a man who may have subclinical prostate cancer or
prostate cancer that has not yet been detected, and also whether it can cause enlargement of benign prostate tissue and contribute to worsening of urinary
symptoms in men. Benign prostatic hypertrophy is another common condition that
impacts quality of life in men as they age by causing reduced ability to urinate.<span style="mso-spacerun: yes;"> </span>Dr. Xiao felt that <a href="http://www.nytimes.com/2011/04/26/health/research/26prognosis.html?_r=0">evidence is lacking</a> to suggest that either of these prostate conditions is affected much by
testosterone therapy and sited data supporting this viewpoint. </span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">It’s good to know that testosterone therapy exists as an option to
help men with symptoms of andropause, which can adversely affect quality of life. However, those of us who have
doctored through the era of the Women’s Health Initiative, which studied the
effects of hormonal therapy for menopause, have to be somewhat cautious about
prescribing treatment for a condition that affects a huge segment of the
population. In the case of estrogen and progestin therapy in women, as
discussed in a recent <a href="http://www.drdialogue.com/2012_09_01_archive.html">blog</a>,<span style="mso-spacerun: yes;"> </span>the pendulum
has swung for, then against, and now recently partially back in favor of a
cautionary approach to post-menopausal hormone replacement for symptom
management during the time immediately following menopause in women. </span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">To date testosterone therapy has been less well studied, and it could
be years before the safety data for testosterone replacement in men is as good
as the data for hormone replacement in women, which has been the subject of
intense research in the previous decade. <o:p></o:p></span></div>
</div>
<div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com0tag:blogger.com,1999:blog-3946741689271235070.post-61951816025953116232012-10-08T16:11:00.000-07:002012-10-08T16:11:11.879-07:00Have Electronic Health Records Led to Fraudulent Upcoding by Physicians?<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglfhHDVeTcEjUjJc6osYcnVAFIHt-VEds3W0Twf9jWV1fXD50aapY1XdId0ZfOrtp_iOBTl465eCYrJXdBkCo-GvnUcbiAg2_1hmq-maz-EPAi9q-jAwZgF5dISwD2AnJTkghArqocdGDg/s1600/juliet+and+lap.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglfhHDVeTcEjUjJc6osYcnVAFIHt-VEds3W0Twf9jWV1fXD50aapY1XdId0ZfOrtp_iOBTl465eCYrJXdBkCo-GvnUcbiAg2_1hmq-maz-EPAi9q-jAwZgF5dISwD2AnJTkghArqocdGDg/s320/juliet+and+lap.jpg" width="178" /></a></div>
<span style="font-family: Calibri;">Over the past several decades medical costs in the United
States have escalated rapidly, exceeding the pace of inflation and threatening
bankrupt to Medicare.<span style="mso-spacerun: yes;"> </span>As we heard in last
week’s presidential debate, different solutions have been proposed on how to
slow Medicare’s growth and reduce cost.<span style="mso-spacerun: yes;"> </span>President
Obama highlighted his administration’s success in tackling fraud and waste
within the system. This strategy appears to be supported across party lines.<span style="mso-spacerun: yes;"> </span>On face value it seems like a good idea, but
what is not entirely clear to those of us within the medical community is how waste
and fraud will be defined.<span style="mso-spacerun: yes;"> </span>I have
discussed this in a previous blog: "<a href="http://www.drdialogue.com/2012/01/when-is-unneeded-care-criminal.html">When is Unneeded Care Criminal?</a><span style="mso-spacerun: yes;">". </span><o:p></o:p></span></div>
<span style="font-family: Calibri;">As reported by the <a href="http://www.nytimes.com/2012/09/22/business/medicare-billing-rises-at-hospitals-with-electronic-records.html?_r=2&hp">New York Times</a> last week, </span><span style="font-family: Calibri;">
<span style="mso-spacerun: yes;"> </span>recently attention has been focused on
going after doctors and hospitals who some believe may be “upcoding” the
complexity of their patient encounters to CMS and other insurers for the purpose of receiving better reiumbursement. Apparently since the advent of electronic health records there has been a trend toward physicians' reporting higher complexity office visits.</span><br />
<span style="font-family: Calibri;"><span style="mso-spacerun: yes;"></span></span><br />
<span style="font-family: Calibri;"><span style="mso-spacerun: yes;"></span>The <a href="http://www.ama-assn.org/ama/pub/amawire/2012-september-26/2012-september-26-general_news2.shtml">AMA (American Medical Association) Wire</a>
reports:</span><br />
<span style="font-family: Calibri;"><blockquote class="tr_bq">
"The Centers for Medicare & Medicaid
Services (CMS) notified the AMA that Connolly, a recovery auditor for what is
commonly known as the Medicare RAC program, will begin auditing how physicians
report CPT® code 99215, used to report evaluation and management (E/M)
services. CMS appears to have also granted Connolly authority to extrapolate
its review of sample claims to potentially recoup funds on 99215 claims it did
not evaluate individually."</blockquote>
</span><span style="font-family: Calibri;"><span style="color: #3b3b3b; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman";">The
AMA strongly objects to these audits and has written a letter to CMS </span></span><span style="font-family: Calibri;"><span style="color: #3b3b3b; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman";">pointing out that: </span></span><div>
<span style="font-family: Calibri;"><blockquote class="tr_bq">
<div>
"Audits of such complex services would result in erroneous payment recoupment and undue expense for physicians and CMS. According to the agency's own report to Congress, 46 percent of appealed Medicare RAC determinations are decided in favor of the physician or other health care professional."</div>
</blockquote>
</span></div>
<span style="font-family: Calibri;"></span><span style="font-family: Calibri;"><br />
What does upcoding mean? Medicare and other payers require that doctors use a convoluted coding system for billing medical visits based on their documented complexity. The system is so complex that for years it has outsmarted doctors who have been tasked with remembering the numerous elements required to justify the level of the visit (1 through 5), and then document the details required to support the billing level. <br />
<br />
The selection of an appropriate billing code, as outlined in an <a href="http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf">89-page guide</a> prepared by CMS, if done correctly would without a doubt take the same amount of time (or perhaps more) as seeing the patient. The end result: most physicians, with limited time and partial recall of the complicated rules, pick the code that they feel best encompasses the visit level based on perceived complexity.<br />
<br />
In the past when doctors dictated or hand wrote patient notes it was more difficult to include all of the historical factors required
to support a higher level billing code. The use of electronic health records,
however, has made the process easier by automating the incorporation of past
medical history, medications, allergies, social history and family history into
clinic notes, thereby allowing physicians to justify a higher level code. Until
recently, based on personal experience, the tendency may have been to “under-code”
complex visits, with fear that documentation would be inadequate to justify a
more complicated billing code.<span style="mso-spacerun: yes;"> </span>In
reality, it is very time consuming to fully document the complex information
that is exchanged in the context of a 15-30 minute office visit. <br />
</span><span style="font-family: Calibri;">The purpose of medical documentation is to convey information.<span style="mso-spacerun: yes;"> </span>Ideally doctors would be able to document
the salient portions of each patient encounter that would help other providers
care for the patient in the future.<span style="mso-spacerun: yes;"> </span>In
many ways electronic health records have helped facilitate medical documentation.<span style="mso-spacerun: yes;"> </span>However, at the same time they have also led
to the inclusions of extraneous information (for the purpose of supporting billing
codes) that one is required to sift through while getting to the meat of the
visit. <o:p></o:p></span><br />
<span style="font-family: Calibri;">What is particularly enraging about these allegations of “upcoding”
and fraud is that finally physicians have a tool to help ease the burden of
Medicare’s inane billing code system—electronic health records; but now, after going
through all the work and tremendous expense of transforming our practices and adopting
these systems, we are threatened by the specter of accusations of fraud for
“upcoding” the same visits that we’ve been “down-coding” for years.<span style="mso-spacerun: yes;"> </span>If politicians would like to eliminate waste
from Medicare why not simplify its billing system so that medical practices
would not have to employ full time coding experts to ensure that their
practices remain fiscally solvent? Of course, this would also eliminate a bunch
of jobs.<o:p></o:p></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
</div>
<div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com0tag:blogger.com,1999:blog-3946741689271235070.post-80113068736903496752012-09-22T11:33:00.000-07:002012-09-22T11:33:11.114-07:00Managing Menopause in 2012<div dir="ltr" style="text-align: left;" trbidi="on">
<a href="http://www.ivillage.com/anatomy-hot-flash/4-a-192574" name="iv:health:menopause-second-talk:lpcontent:l8:anatomy-hot-flash"><img src="http://www.ivstatic.com/files/et/imagecache/300hstrict/files/blog_articles/menopause.hotflash.jpg" /></a><br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Recently I hosted an evening discussion for </span><a href="http://www.ppcatl.com/"><span style="color: blue; font-family: Calibri;">Personalized Primary Care Atlanta</span></a><span style="font-family: Calibri;"> members on
the topic of menopause. Here is a summary of our discussion:<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0in 0in 0pt 0.5in; mso-list: l2 level1 lfo1; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Menopause is defined by no menstrual cycle for
one year.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l2 level1 lfo1; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">The average age of menopause in the US is 51.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l2 level1 lfo1; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">90% if American women experience menopause
between ages 45 and 55.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l2 level1 lfo1; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Prior to menopause women go through a period of
transition, often referred to as perimenopause.<span style="mso-spacerun: yes;">
</span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l2 level1 lfo1; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">During this time of transition women may begin
by having irregular menstrual cycles with changes in cycle length and periods
of heavier or lighter flow.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l2 level1 lfo1; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Later in transition women may skip one or more
menstrual cycles and may begin to have symptoms related to menopause. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l2 level1 lfo1; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Irregular menses relate to anovulatory cycles
and low levels of progesterone<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l2 level1 lfo1; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">For several years prior to menopause women may
have higher than normal estradiol levels and lower than normal progesterone
levels.<span style="mso-spacerun: yes;"> </span>FSH levels may also be high.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpLast" style="margin: 0in 0in 10pt 0.5in; mso-list: l2 level1 lfo1; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Following menopause FSH levels are high and estrogen
and progesterone levels are low, however menopause is not defined by hormonal
levels, and because of individual differences in hormone levels and also normal
fluctuations in levels throughout the cycle, hormone levels can be difficult to
use as parameters of change.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Common symptoms of menopause are related to a decline in
estrogen levels. For most women symptoms last several years. <span style="mso-spacerun: yes;"> </span>However, in some, symptoms may continue for up
to 10 years. About 10% of women in their sixties continue to have hot flashes<b style="mso-bidi-font-weight: normal;">. <o:p></o:p></b></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><b style="mso-bidi-font-weight: normal;"><u><span style="mso-bidi-font-size: 11.0pt;">Menopause Symptoms</span></u></b><span style="mso-bidi-font-size: 11.0pt;">:<o:p></o:p></span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0in 0in 0pt 0.5in; mso-list: l3 level1 lfo2; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Hot flashes (last 2-4 minutes, affect the upper
body and face, occur frequently at night)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l3 level1 lfo2; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Insomnia (may be a manifestation of temperature
regulation trouble—hot flashes)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l3 level1 lfo2; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Heart Palpitations<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l3 level1 lfo2; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Forgetfulness<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l3 level1 lfo2; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Changes in sex drive<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l3 level1 lfo2; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Irritability<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l3 level1 lfo2; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Vaginal dryness<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l3 level1 lfo2; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Trouble with control of urination<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpLast" style="margin: 0in 0in 10pt 0.5in; mso-list: l3 level1 lfo2; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Changes in body composition—reduced muscle mass<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><b style="mso-bidi-font-weight: normal;"><u><span style="mso-bidi-font-size: 11.0pt;">Menopause Risks</span></u></b><span style="mso-bidi-font-size: 11.0pt;">:<o:p></o:p></span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Menopause increases the risk of osteoporosis. Women lose
bone density quickly during the first five years following menopause.<span style="mso-spacerun: yes;"> </span>Menopause is also associated with an increased
risk of cardiovascular disease. Women develop more insulin resistance, lower
HDL levels and higher LDL cholesterol.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<b style="mso-bidi-font-weight: normal;"><u><span style="mso-bidi-font-size: 11.0pt;"><span style="font-family: Calibri;">Managing Menopause Symptoms:<o:p></o:p></span></span></u></b></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Approaches to managing menopausal symptoms include hormonal
therapies, off -label use of non-hormonal therapies, and natural remedies. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: Calibri;">Hormone Replacement
Therapy<o:p></o:p></span></b></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0in 0in 0pt 0.5in; mso-list: l1 level1 lfo3; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Hormone replacement therapy is no longer
recommended for menopausal women for the purpose of prevention.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l1 level1 lfo3; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Hormone replacement therapy has been extensively
studied in the form of conjugated equine estrogen in a dose of 0.625 mg and medroxyprogesterone
at a dose of 2.5 mg in postmenopausal women with an average age of 63 in the </span><a href="http://www.nhlbi.nih.gov/whi/index.html"><span style="color: blue; font-family: Calibri;">Women’s Health Initiative</span></a><span style="font-family: Calibri;">
trial.<span style="mso-spacerun: yes;"> </span>This trial involved approximately
161,000 women and reported on a number of outcomes.<span style="mso-spacerun: yes;"> </span>The Estrogen and Progesterone arm of the
trial was terminated in 2002 and found that women using the two hormones had a
higher risk of blood clots, heart attacks, strokes, and breast cancer.<span style="mso-spacerun: yes;"> </span>The same women had a lower risk of colon
cancer and bone fracture. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l1 level1 lfo3; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Women in the Estrogen alone part of the study
had higher risk of strokes and blood clots, but not breast cancer and heart
attacks.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l1 level1 lfo3; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Three years following discontinuation of the
study women treated with Estrogen and Progesterone continued to have a higher
risk of cancer, including lung cancer.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l1 level1 lfo3; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">A subgroup analysis of the study found that most
of the risk conferred by hormone replacement therapy was related to the age of
the treated women. Women treated from the time of menopause forward for five
years did not experience significant increases in health risk.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpLast" style="margin: 0in 0in 10pt 0.5in; mso-list: l1 level1 lfo3; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">For a sense of the magnitudes of health risk I
recommend looking at the handbook <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: Calibri;">Changes in Practice a
Decade Later<o:p></o:p></span></b></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Hormone replacement remains the most effective treatment of
menopausal symptoms. However, not all women require hormone replacement to get
through menopause. Currently women’s health experts prefer to use the lowest
dose of hormones available to control symptoms. Today, oral estrogen is
available in one half the dosage that was studied in the Women’s Health
Initiative study. There are </span><a href="http://www.menopause.org/docs/default-document-library/htcharts.pdf?sfvrsn=2"><span style="color: blue; font-family: Calibri;">several
different types of estrogen and progesterone available</span></a><span style="font-family: Calibri;"> on the market.<span style="mso-spacerun: yes;"> </span>All estrogens appear to carry a similar risk
of blood clot.<span style="mso-spacerun: yes;"> </span>However, it remains uncertain whether
different types of estrogens and progestins confer different health risks. In
the case of progestins, they do seem to vary more in their activity and side
effect profiles. The adverse effects of hormone replacement are speculated to
relate to dose. Current practice has shifted toward the use of transdermal estrogen
and progesterone through patches—also available in low dose. Transdermal estrogen
confers a lower risk of deep venous thrombosis, and it is thought by some that to
be safer with respect to other health outcomes.<span style="mso-spacerun: yes;">
</span>Vaginal estrogen is an effective means to treat the urogenital symptoms
of menopause—vaginal dryness and urinary symptoms, and does not require
systemic progesterone to protect the uterus as do oral and transdermal
estrogen.<span style="mso-spacerun: yes;"> </span>It is felt that if use of
hormone replacement is limited to the first five years following the time of natural
menopause (around age 51), the cardiovascular risks may be lower. Tapering
hormonal therapy slowly after several years may produce fewer symptoms than stopping
cold turkey and can help facilitate the transition to menopause for some women.<span style="mso-spacerun: yes;"> </span>Some women may choose to live with the health
risks related to hormone replacement and may continue treatment for longer than
five years—reporting improved quality of life.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: Calibri;">What are
“Bioidentical Hormones?”<o:p></o:p></span></b></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Bioidentical hormones typically refers to custom compounds of
hormones that are also manufactured and marketed as pharmaceuticals. However,
bioidentical hormones are not tested and regulated. Given the range of hormone
replacement now available on the market with numerous dosing options, many women’s
health experts agree that it is safer to use products that have been more
thoroughly investigated and that are regulated in the U.S. through the FDA.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><b style="mso-bidi-font-weight: normal;">Non-hormonal options</b>
for treating hot flashes are available as off-label use of prescription
medications and include:<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0in 0in 0pt 0.5in; mso-list: l0 level1 lfo4; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Selective Serotonin Reuptake Inhibitors and
Selective Norepinephrine Reuptake Inhibitors: paroxetine (Paxil), venlafaxine
(Effexor), bupropion (Wellbutrin), fluoxetine (Prozac)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in; mso-list: l0 level1 lfo4; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Gabapentin (a seizure drug)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpLast" style="margin: 0in 0in 10pt 0.5in; mso-list: l0 level1 lfo4; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Clonidine (a blood pressure drug)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: Calibri;">Natural Products<o:p></o:p></span></b></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0in 0in 0pt 0.5in; mso-list: l4 level1 lfo5; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Plant Based Estrogens (Phytoestrogens)
/Soy:<span style="mso-spacerun: yes;"> </span>Not FDA regulated, might work in
the body like a weak estrogen, might also have some health risk.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoListParagraphCxSpLast" style="margin: 0in 0in 10pt 0.5in; mso-list: l4 level1 lfo5; text-indent: -0.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-family: Calibri;">Black Cohosh : Also not regulated by FDA, lack
of conclusive evidence that it helps, but has a fairly good safety record<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">For more information I also recommend </span><span style="font-family: Calibri;">the:</span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<a href="http://www.menopause.org/"><span style="color: blue; font-family: Calibri;">North American Menopause Society (NAMS)
website</span></a> and<span style="font-family: Calibri;"> </span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">the handbook:<span style="mso-spacerun: yes;"> </span></span><a href="http://www.nhlbi.nih.gov/health/women/pht_facts.pdf"><span style="color: blue; font-family: Calibri;">Facts About Menopausal
Hormone Therapy</span></a><span style="font-family: Calibri;">. <span class="MsoHyperlink"><span style="color: windowtext; text-decoration: none; text-underline: none;"><o:p></o:p></span></span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><em>Or, contact me directly at </em></span><a href="mailto:drmavromatis@ppcatl.com"><span style="color: blue; font-family: Calibri;"><em>drmavromatis@ppcatl.com</em></span></a><o:p></o:p></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<o:p><span style="font-family: Calibri;"> </span></o:p></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
</div>
</div>
<div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com0tag:blogger.com,1999:blog-3946741689271235070.post-64021639972959731262012-08-03T18:34:00.000-07:002012-08-03T18:34:24.918-07:00Physician Self-Disclosure: Helpful or Harmful?<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiN8kj7tYAyc81qXE1SvGGr8FCvCWjNpRJgJayy6otMAKWKeDvNHirrH_oo4N-uuZg6FqMl7RoLkRWs9lSeS_-_nMkqd6TetjfHzZRxqB8xTsPfvQyp5tSaWW17wfHhGiYxtte0qcFJlSoS/s1600/Meredith+patient.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="249" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiN8kj7tYAyc81qXE1SvGGr8FCvCWjNpRJgJayy6otMAKWKeDvNHirrH_oo4N-uuZg6FqMl7RoLkRWs9lSeS_-_nMkqd6TetjfHzZRxqB8xTsPfvQyp5tSaWW17wfHhGiYxtte0qcFJlSoS/s320/Meredith+patient.jpg" width="320" /></a></div>
<span style="font-family: Calibri;">How much should doctors reveal about themselves to patients?<span style="mso-spacerun: yes;"> </span></span><br />
<span style="font-family: Calibri;">Whether or not “self-disclosure” is an
effective communication strategy in the doctor-patient relationship has been
debated.<span style="mso-spacerun: yes;"> </span>In fact, some studies have
demonstrated that doctors who talk about themselves more are
rated more poorly by patients than those who are more private. This topic has
been of interest to me and I have written about it in my blog: <span style="mso-spacerun: yes;"> </span><a href="http://www.drdialogue.com/2010/02/doctor-patient-friend-blurring.html">Doctor, Patient, Friend: <span style="mso-spacerun: yes;"> </span>Blurring the Boundaries</a>, </span><span style="font-family: Calibri;">
<span style="mso-spacerun: yes;"> </span>and explored it further in a recent book
chapter in <a href="http://store.newforums.com/Social-Media-in-Medicine-UCT004.htm">Social Media in Medicine</a>.<span style="mso-spacerun: yes;"> </span></span><br />
<br />
<span style="font-family: Calibri;">In the case of <a href="http://www.gtaan.gatech.edu/meetings/handouts/MazerFacebook.pdf">teachers and students</a>, communication
strategies that promote “immediacy” have been found to have positive results in
terms of promoting learning by creating a more open classroom environment. <span style="mso-spacerun: yes;"> </span></span><span style="font-family: Calibri;">Humor and self-disclosure are two strategies that promote immediacy. But, are
these communication strategies effective in medicine also? I hypothesize that
they are. <o:p></o:p></span><br />
<div style="text-align: left;">
</div>
<div style="text-align: left;">
<span style="font-family: Calibri;">Recently a patient visited me to follow up after an E.R.
visit. While she was in the office I recounted to her a personal tidbit that
related to her day in the E.R.<span style="mso-spacerun: yes;"> </span>While
she and I were on the phone and as I was advising her the preceding Saturday afternoon, I had walked
outside of a local sub-shop, Dave’s Cosmic Subs, seeking out private place to
talk. On doing so, I had stepped beneath a tree into a pile of fire ants and was
bitten all over my feet, which caused a degree of distraction.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>For
this reason I ended the phone call somewhat abruptly and later called her back. Was
this self-disclosure helpful? She found it amusing, but we didn’t lose much
time over the conversation. A few days later she made mention of it again as we chuckled together about life's annoyances.</span></div>
<div style="text-align: left;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt; text-align: left;">
<span style="font-family: Calibri;">In another recent conversation with a patient who was
considering various hormonal options for peri-menopausal symptoms I revealed my
personal experience with using a Mirena IUD.<span style="mso-spacerun: yes;">
</span>Several weeks later she decided this might be a good option for her as
well.<o:p></o:p></span></div>
<div style="text-align: left;">
<span style="font-family: Calibri;">Were these personal self-disclosures to my patients helpful
or harmful? In the role of patient, I’ve been to see physicians who recount
personal stories during an office visit that seem to take time away from my
talk-time.<span style="mso-spacerun: yes;"> In a dentist's office this can provide pleasant distraction as one is held captive with her mouth open, but in a doctor's office </span>it can be annoying to a
patient when one knows that time is limited. <span style="mso-spacerun: yes;"> </span>Nonetheless, physicians, with their expert
knowledge of medicine, process medical information in the context of their own
lives in ways that are sometimes helpful to patients to learn about by way of
example.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div style="text-align: left;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt; text-align: left;">
<span style="font-family: Calibri;">I have, on more than one occasion, shared the story: when I
turned forty I was diagnosed with hypertension.<span style="mso-spacerun: yes;">
</span>Three months after stopping oral contraceptive pills my blood pressure
normalized.<span style="mso-spacerun: yes;"> </span>I suspect that I will
eventually need blood pressure medication, in light of my strong family history
and current readings (130s/80s), and also despite my normal BMI and daily exercise. However, I
will try to stave it off for a few more years. Are these tidbits of
personal experience helpful for me to share with my patients? <o:p></o:p></span></div>
<div style="text-align: left;">
<span style="font-family: Calibri;">As physicians increasingly engage in social media the
question of appropriate self-disclosures becomes more relevant.<span style="mso-spacerun: yes;"> </span>Should a doctor “friend” a patient on
Facebook? How should a physician conduct his or herself on Twitter?<span style="mso-spacerun: yes;"> </span>Self-disclosure is the norm for much
participation in social media. The AMA has published guidelines for social
media use by medical professionals.<span style="mso-spacerun: yes;"> </span>My own
theory is that physician self-disclosure can help promote intimacy and
trust between doctor and patient—qualities that are increasingly lacking in the
patient-physician relationship.<span style="mso-spacerun: yes;"> </span>I might
point out that in the case of social media, self- disclosures do not occur in
the context of office visits, and as such are <b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;">extra</i> </b>communications that
don’t take time away from a patient’s precious appointment time.<o:p></o:p></span></div>
<div style="text-align: left;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt; text-align: left;">
<span style="font-family: Calibri;">Recently I was interested to <a href="http://techland.time.com/2012/05/10/like-to-brag-on-facebook-or-twitter-thats-because-self-disclosure-is-like-eating-and-sex-says-study/">read about a series of studies</a>
published in the Proceedings of the National Academy of Science. </span><span style="font-family: Calibri;">The studies, led by Harvard psychology researchers <span lang="EN" style="color: black; mso-ansi-language: EN; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Diana I. Tamir and Jason P.
Mitchell, made the relatively intuitive discovery: <a href="http://wjh.harvard.edu/~dtamir/Tamir-PNAS-2012.pdf">humans get a biochemical buzz from self-disclosure</a>.<span style="mso-spacerun: yes;"> </span>By inference,
perhaps doctors who share more with their patients are happier with their
patient interactions than those who are more reserved, and perhaps those
positive feelings translate into a more effective health care experience.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> No one knows, and m</span></span></span><span style="font-family: Calibri;">ore
study is needed to uncover exactly what forms of physician self-disclosure are
helpful to patients and what forms are more self-serving, or “narcissistic,” detracting from the patient-physician relationship.</span></div>
<div style="text-align: left;">
</div>
<div class="MsoNormal" style="margin: 0in 0in 10pt; text-align: left;">
<br /></div>
<div style="text-align: left;">
</div>
</div><div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com0tag:blogger.com,1999:blog-3946741689271235070.post-19755916098673439352012-07-12T15:29:00.001-07:002012-07-13T03:47:43.576-07:00Are Annual Physical Exams Necessary<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1ReId8Au-CjarEYnVVtjKXz2yqrBnvm7WjdUYXcBjw24trDRqGRhw91ZxO41QD1GLkFhHEPuZWrGu3EppkTb6SsV_eekwT_whouFfcwBKlbNKZ7Wa4SAMPosoFAAnnR6e5ob9KkPZqJlZ/s1600/_MG_6488+(604x1165).jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1ReId8Au-CjarEYnVVtjKXz2yqrBnvm7WjdUYXcBjw24trDRqGRhw91ZxO41QD1GLkFhHEPuZWrGu3EppkTb6SsV_eekwT_whouFfcwBKlbNKZ7Wa4SAMPosoFAAnnR6e5ob9KkPZqJlZ/s200/_MG_6488+(604x1165).jpg" width="102" /></a></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Recently a physician reporter for the New York Times, Elisabeth
Rosenthal, argued in the cover article of the Sunday Review that routine
physicals are in many ways pointless, and perhaps even dangerous.<span style="mso-spacerun: yes;"> </span>In the article, entitled “<a href="http://www.nytimes.com/2012/06/03/sunday-review/lets-not-get-physicals.html?pagewanted=all">Let’s Not Get Physicals</a>,” </span><span style="font-family: Calibri;">
Dr. Rosenthal goes on to point out that many routine tests performed during
physicals --EKG’s, pap smears and blood work, are unnecessary. In my opinion,
Dr. Rosenthal’s front page skepticism of the utility of the annual ritual
misses the key point and sets a dangerous tone.<span style="mso-spacerun: yes;">
</span>As every good primary care physician knows, the key benefit of an annual
check-up (aka “physical”) is not the litany of tests ordered, but the opportunity
it provides to do a complete review of a patient’s medical history and risk
factors.<span style="mso-spacerun: yes;"> </span>The “annual physical” also
provides an opportunity for healthy people to get to know their physicians and
vice versa, so that when illness arises, as it always will, the physician will
understand a patient’s personality and healthy baseline. <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<span style="font-family: Calibri;">After years of criticism by proponents of prevention
Medicare recently started to cover an annual exam, which is referred to as a “<a href="http://www.medicare.gov/navigation/manage-your-health/preventive-services/medicare-physical-exam.aspx">Wellness Exam</a>.”<span style="mso-spacerun: yes;"> </span></span><span style="font-family: Calibri;">
The Medicare preventive exam, which became a covered benefit in 2011, emphasizes
history-taking as opposed to testing, which in my view is appropriate. <span style="mso-spacerun: yes;"> </span>The Affordable Care Act also regulates the
<a href="http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html">provision of preventive care</a> by health plans requiring that plans provide a
core set of preventive services without requiring a co-pay, co-insurance, or
deductible. </span><br />
<br />
<span style="font-family: Calibri;">While the physician author of the New York Times piece surely
understands many of her own personal risk factors for disease and also the signs
and symptoms of potentially serious underlying conditions, the general public
does not have this expert knowledge. Why shun a once a year, hour-long (or, as
is more often the case these days, 20 minute-long) visit to a medical expert to
review one’s personal health profile, risk factors and family history? <span style="mso-spacerun: yes;"> </span>I suppose that Dr. Rosenthal’s point is to
de-emphasize the testing component.<span style="mso-spacerun: yes;"> </span>In
my view, if anything many individuals could benefit from more frequent (biannual
or quarterly) preventive checks to keep them on track with their health goals
and risk factors—perhaps this would keep more folks out of the ER and hospital.
<span style="mso-spacerun: yes;"> </span>As to the “testing” component of the
annual physical, the visit provides an opportunity for patient and physician to
discuss the state of the art, information that the patient might be reading
online, and the evidence for and against screening for particular conditions. Which
screening tests health insurance should pay for is a separate question. The
issue here may be semantic—should it be called a "physical," a "wellness
visit," or a "preventive check-up--" but, let’s not get rid of the annual visit.<o:p></o:p></span></div><div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com0tag:blogger.com,1999:blog-3946741689271235070.post-47932059857917900392012-06-21T05:06:00.003-07:002012-06-21T05:06:42.951-07:00Two Conversations About Health Care<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-xst1f0xpblxG9zNsMYcxekIIK1wrwLsv7txV7mhRfeVvxNOSxrvCPoMHT5CnsgRbjakJMqJQ9HO0QYk9bcrHlPSa_addJ9WFhUWDFJwhX4lbcR2S4_cNll15HYh_huYOoxNYNoN-7fnV/s1600/Juliet+and+laptop+%2528800x1200%2529+%2528427x640%2529.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-xst1f0xpblxG9zNsMYcxekIIK1wrwLsv7txV7mhRfeVvxNOSxrvCPoMHT5CnsgRbjakJMqJQ9HO0QYk9bcrHlPSa_addJ9WFhUWDFJwhX4lbcR2S4_cNll15HYh_huYOoxNYNoN-7fnV/s200/Juliet+and+laptop+%2528800x1200%2529+%2528427x640%2529.jpg" width="132" /></a></div>
<span style="font-family: Calibri;">Last weekend I was struck by two conversations that I had
with acquaintances about recent experiences that they had had with their primary
care physicians.<span style="mso-spacerun: yes;"> </span>The first occurred at my
local pool. A fellow swimmer asked me if I took new Medicare patients. <span style="mso-spacerun: yes;"> </span>She bemoaned that she was abandoned--her
beloved physician of over 20 years had sent out a letter announcing that
she would no longer accept Medicare patients. My friend
had recently gone on Medicare.<span style="mso-spacerun: yes;"> </span>She
speculated about her physician’s motives, but felt personally
rejected, or “fired.”<span style="mso-spacerun: yes;"> </span>After she
explained her situation, I affirmed, “I do take new Medicare patients,” but
qualified my response with a description of my concierge model primary care
practice, which requires an annual retainer fee from members in exchange for improved
access to me and other amenities, including my guaranteed smaller patient panel size.<span style="mso-spacerun: yes;"> </span></span><br />
<br />
<span style="font-family: Calibri;"><span style="mso-spacerun: yes;"></span>I started a retainer fee primary care practice
after having been in a traditional fee for service practice for 12 years and
then after taking a year’s leave of absence from clinical medicine. Many of my old
patients sought me out, though currently most patients enrolling in my practice
are new patients looking for a better primary care experience.<span style="mso-spacerun: yes;"> </span>My swimming friend nodded that she understood
and that her mother had a concierge physician--she was familiar with the
concept and could see its value, though was going to have to decided whether she could afford it.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">My second conversation was at a friend’s 59<sup><span style="font-size: x-small;">th</span></sup>
birthday party the following evening. The party was held at the upscale home of a middle-aged, gay male couple—friends of my friend. As I chatted with
one of the hosts, a self-employed professional, he asked what kind of medicine
I practiced. I explained that I was an internist, or a primary care physician
for adults, and that I was in solo practice in Atlanta after practicing at the Emory
Clinic for 12 years.<span style="mso-spacerun: yes;"> </span>As I spoke he
announced that he was in need of a new primary care physician. He went on to
explain that his physician, who he was very fond of, had converted his practice
last year to a concierge model practice—requiring patients to pay a membership
fee in order to remain in his care.<span style="mso-spacerun: yes;"> </span>He
had made the decision not to enroll in the new practice model, in part because
he was already paying a high deductible for care under his insurance and he was
unsure how the annual fee would impact his out of pocket cost. <span style="mso-spacerun: yes;"> </span></span><span style="font-family: Calibri;">Before the host of the party said more (not
wanting him to feel awkward with me), I explained that my practice was a
similar model. He and I spoke for about twenty minutes about the problems in
primary care and the reasons that primary care doctors were seeking out new
practice models.<span style="mso-spacerun: yes;"> </span>The man with whom I chatted
pulled over his partner, who had been cared for by the same physician.<span style="mso-spacerun: yes;"> </span>His partner reacted to our discussion—“but
this is not a solution for our country’s health care problems.” I agreed, and
we talked about cost and discussed new models of health care, including the
Medical Home and Accountable Care Organizations, both of which have yet to
materialize as answers for doctors like me. <span style="mso-spacerun: yes;"> </span>He went on to assert that he felt that one solution
to the problems in medicine would be to produce more doctors, while at the same
time to lower the cost of educating them.<span style="mso-spacerun: yes;">
</span>Personally, I doubt that producing more doctors in general, will improve
primary care, nor will it reduce cost; though, better incentivizing primary
care career choices would be helpful.<o:p></o:p></span></div>
<span style="font-family: Calibri;"></span><br />
<span style="font-family: Calibri;">These conversations illustrate that for the American
populous the main problems in health care today are access and affordability. <span style="mso-spacerun: yes;"> </span>For primary care physicians the
problem is not so simple.<span style="mso-spacerun: yes;"> The "system" has failed to support our work in a manner that is conducive to providing the care that we feel patients deserve. Patients may or may not be aware of the impact of this failure on our practice of medicine. </span></span><br />
<br />
<span style="font-family: Calibri;"><span style="mso-spacerun: yes;"></span></span><span style="font-family: Calibri;">Most Americans equate spending money on health insurance with spending money on
their physicians. Primary care physicians see relatively little of the money
that consumers put toward their health insurance premiums. Our fees and
reimbursement rates are relatively low in comparison to the exorbitant fees for
tests, procedures, E.R. visits, and hospitals stays. As our overhead expense
has increased, in part because of the administrative hassle involved in getting
money from health insurance companies, we have responded by increasing the number
of patients seen per day and our panel sizes to the point where many (including
myself) feel that quality of care and the patient-physician relationship is
compromised. </span><br />
<br />
<span style="font-family: Calibri;">“Concierge medicine” and the abandonment of Medicaid, and now
Medicare, by primary care practices are a reaction to these pressures, which
have changed the nature of general practice and offer solutions to protect the
personal aspects of the physician-patient relationship.<span style="mso-spacerun: yes;"> </span>However, clearly these motives remain poorly
understood by the average American consumer, who is faced with rising out of
pocket medical costs to pay for health insurance, and increasingly feels burdened
with excessive health care expense. <o:p></o:p></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">The disconnect leaves doctors like me in a conundrum. Do we continue to
work within the confines of a system that has failed to protect primary care as
an honored specialty? Do we compromise the care that we deliver in order to
preserve access? <span style="mso-spacerun: yes;"> </span>Or, do we jump ship and
force change by creating new models of care—models of care that patients are
increasingly seeking out as they recognize their value? It can be a difficult
position to be in.<o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<br /></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<br /></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<br /></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<br /></div>
</div><div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com0tag:blogger.com,1999:blog-3946741689271235070.post-70203804617937698072012-06-07T16:19:00.001-07:002012-06-07T16:19:05.803-07:00"How can I raise my HDL?"<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-family: Calibri;"><span style="font-size: 14pt;"></span></span><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7RPx91YDl8vEN-V87beA3aE9pTmNl5cEDythQeqrFzq0jG48fsAaBrPHqkjWkhpE9gbkKueBBKYtiuPyAO1Hz2j_TTzWw852lQAxA4uevkn99Ued1PLJb5g3z-VwZ_gtFNaDB_0got5Up/s1600/red+wine.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7RPx91YDl8vEN-V87beA3aE9pTmNl5cEDythQeqrFzq0jG48fsAaBrPHqkjWkhpE9gbkKueBBKYtiuPyAO1Hz2j_TTzWw852lQAxA4uevkn99Ued1PLJb5g3z-VwZ_gtFNaDB_0got5Up/s1600/red+wine.jpg" /></a><span style="font-size: 14pt;"><em></em></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><span style="font-size: 14pt;">"How can I raise my HDL?" I have often been asked this
question during my years of practice.<span style="mso-spacerun: yes;">
</span>Lifestyle strategies include smoking cessation, exercise, and alcohol in
moderation. However, evidence is mounting that perhaps this is not
the salient question. </span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-size: 14pt;"><span style="font-family: Calibri;">Three recent studies suggest
that raising HDL levels may not be helpful in terms of reducing one’s risk of
cardiovascular disease.</span></span></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0in 0in 0pt 0.75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<span style="font-size: 14pt; line-height: 115%; mso-bidi-font-family: Calibri;"><span style="mso-list: Ignore;"><span style="font-family: Calibri;">1)</span><span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-size: 14pt; line-height: 115%;"><span style="font-family: Calibri;">The
<a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1107579">AIM-HIGH</a> study compared niacin, which raises HDL, lowers LDL and lowers
triglycerides, to placebo in patients at high risk for cardiovascular disease
events (death, myocardial infarction and stroke). </span><span style="font-family: Calibri;">
<span style="mso-spacerun: yes;"> </span>The study was stopped because an interim
analysis showed that patients taking niacin experienced no benefit from the
drug with regard to preventing cardiovascular events.</span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<span style="font-size: 14pt; line-height: 115%; mso-bidi-font-family: Calibri;"><span style="mso-list: Ignore;"><span style="font-family: Calibri;">2)</span><span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-size: 14pt; line-height: 115%;"><span style="font-family: Calibri;"><a href="http://www.theheart.org/article/1395141.do">Dal-OUTCOMES</a>
was a study in which dalcetrapib, a new drug which causes circulating HDL
levels to increase by a mechanism different from niacin (CETP inhibition),<span style="mso-spacerun: yes;"> </span>was compared to placebo in patients at high
risk for cardiovascular events . </span><span style="font-family: Calibri;">This study was also stopped early after an interim
analysis showed that patients taking the dalcetrapib did not have fewer events
than those given placebo.<span style="mso-spacerun: yes;"> </span>Some years
ago, another CETP inhibitor, <a href="http://atvb.ahajournals.org/content/27/2/257.full">torceptrapib</a>, was found to actually increase
cardiovascular events (though this was blamed on torcetrapib’s<span style="mso-spacerun: yes;"> </span>side effects of increasing aldosterone levels
and slightly raising blood pressure; dalcetrapib has no such side effects to
blame).</span></span><span style="font-family: Calibri;"> </span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<span style="font-size: 14pt; line-height: 115%; mso-bidi-font-family: Calibri;"><span style="mso-list: Ignore;"><span style="font-family: Calibri;">3)</span><span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span style="font-size: 14pt; line-height: 115%;"><span style="font-family: Calibri;">A
recent study looked at people with genetic variations in cholesterol levels—one
group with low LDL levels, and another with high HDL levels. People with genetically
low LDL levels had fewer cardiovascular events than those with genetically higher
LDL levels, reinforcing the concept that lowering LDL prevents cardiovascular
disease. However, patients with <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2960312-2/fulltext">genes that resulted in high HDL levels</a> had
similar rates of cardiovascular events to those who have genes resulting in
lower HDL levels. </span></span></div>
<div style="text-align: left;">
<br /> </div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt; mso-add-space: auto;">
<span style="font-size: 14pt; line-height: 115%;"><span style="font-family: Calibri;">Epidemiological data has linked higher
HDL levels to an increased risk of cardiovascular disease.<span style="mso-spacerun: yes;"> </span>However the results of these recent studies call into question the utility of trying to raise HDL as a means to
prevent cardiovascular disease. </span></span><br />
<br />
<span style="font-size: 14pt; line-height: 115%;"><span style="font-family: Calibri;">In a separate study conducted by senior author
Frank Sachs it was found that not all HDL is created equally. This study,
published in April 2012 in the Journal of the American Heart Association, found
that HDL molecules that contained <a href="http://www.hsph.harvard.edu/news/press-releases/2012-releases/hdl-cholesterol-heart-disease.html">apoprotein C-III</a> actually were associated with
increased risk of heart disease, compared with HDL that did not contain this “pro-inflammatory"
protein. <span style="mso-spacerun: yes;"> </span></span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt; mso-add-space: auto;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlIQn5fyRmjzcQU9AQJcVazTphlOlazb3A6Lq6sn_gvGKfdmRgXYUdJBnMiBUkDfUmiK7w7x7MIrkGrz1B-viYNHBak5TxJFF8xlEJD0t-2w5RawX42m_3wIizu-BFAc1wtSqK9USti5b0/s1600/HDL+and+CVD.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlIQn5fyRmjzcQU9AQJcVazTphlOlazb3A6Lq6sn_gvGKfdmRgXYUdJBnMiBUkDfUmiK7w7x7MIrkGrz1B-viYNHBak5TxJFF8xlEJD0t-2w5RawX42m_3wIizu-BFAc1wtSqK9USti5b0/s320/HDL+and+CVD.png" width="320" /></a></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt; mso-add-space: auto;">
<br /></div>
<div style="text-align: left;">
</div>
<div class="MsoListParagraphCxSpLast" style="margin: 0in 0in 10pt; mso-add-space: auto;">
<span style="font-size: 14pt; line-height: 115%;"><span style="font-family: Calibri;">Practically, what does this mean? Those
with low HDL should continue to pay attention to this as a marker that is known
to be associated with higher cardiovascular risk.<span style="mso-spacerun: yes;"> </span>However for now it remains uncertain whether
HDL is actually <em><strong>causally</strong></em> related to higher cardiovascular risk. </span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><span style="color: black; font-size: 14pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">In the words of </span><span style="color: black; font-size: 14pt; mso-ascii-font-family: Calibri; mso-bidi-font-size: 11.5pt; mso-hansi-font-family: Calibri;"><a href="http://www.nytimes.com/2012/05/17/health/research/hdl-good-cholesterol-found-not-to-cut-heart-risk.html">Sekar Kathiresan</a></span><span style="color: black; font-size: 14pt; mso-bidi-font-size: 11.5pt;"> (as reported in
the New York Times)</span><span style="font-size: 14pt;"> </span><span style="color: black; font-size: 14pt; mso-ascii-font-family: Calibri; mso-bidi-font-size: 11.5pt; mso-hansi-font-family: Calibri;">, </span><span style="color: black; font-size: 14pt; mso-bidi-font-size: 11.5pt;">D</span><span style="color: black; font-size: 14pt; mso-ascii-font-family: Calibri; mso-bidi-font-size: 11.5pt; mso-hansi-font-family: Calibri;">irector of preventive cardiology at Massachusetts General
Hospital</span><span style="color: black; font-size: 14pt; mso-bidi-font-size: 11.5pt;">,</span><span style="color: black; font-size: 14pt; mso-ascii-font-family: Calibri; mso-bidi-font-size: 11.5pt; mso-hansi-font-family: Calibri;"> a
geneticist at the Broad Institute of M.I.T</span><span style="color: black; font-size: 14pt; mso-bidi-font-size: 11.5pt;">, and investigator in the recent genetic
study:</span></span></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0in 0in 0pt 0.75in; mso-add-space: auto;">
<span style="color: black; font-size: 14pt; line-height: 115%; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;"><span style="font-family: Calibri;">“The number of factors that track with low HDL is a mile long:<span style="mso-spacerun: yes;"> </span></span><a href="http://health.nytimes.com/health/guides/symptoms/morbid-obesity/overview.html?inline=nyt-classifier" title="In-depth reference and news articles about Obesity."><span style="color: #004276;"><span style="font-family: Calibri;">obesity</span></span></a><span style="font-family: Calibri;">, being sedentary, smoking, insulin
resistance, having small LDL particles, having increased cholesterol in remnant
particles, and having increased amounts of coagulation factors in the blood.<span style="mso-spacerun: yes;"> </span>Our hypothesis is that much of the
association may be due to these other factors.”</span></span><span style="font-size: 14pt; line-height: 115%; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;"><o:p></o:p></span></div>
<div style="text-align: left;">
</div>
<div style="text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0in 0in 10pt; mso-add-space: auto;">
<span style="font-size: 14pt; line-height: 115%;"><span style="font-family: Calibri;">For now a person with low HDL has
less reason to focus on using available HDL-raising treatments and drugs, and
more reason to do <i style="mso-bidi-font-style: normal;">everything else</i> to reduce
his/her risk of heart disease—including getting LDL cholesterol down to recommended
levels, or even lower.</span></span><br />
<br />
<span style="font-size: 14pt; line-height: 115%;"><em>Guest Co-author: </em><a href="http://www.med.emory.edu/faculty/profile_bio.cfm?id=7406"><em>Kreton Mavromatis, MD, FACC</em></a><em>, Assistant Professor of Medicine, Division of Cardiology, Emory University, Director of the Cardiac Catheterization Laboratory, Atlanta VA Medical Center and Juliet Mavromatis, MD, FACP, Adjunct Clinical Assistant Professor of Medicine, Emory University</em></span><br />
</div>
<div style="text-align: left;">
<em></em></div>
</div><div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com0tag:blogger.com,1999:blog-3946741689271235070.post-14017728028628060992012-05-25T12:48:00.001-07:002012-05-25T12:48:53.177-07:00Recommended Care, Says Who?<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8nsruMNy6orO0Xe8Ch3sry7yxVENajaoUO7Z7xcWUz-EeMwQwgBEpSTr_m1P3tKUfZzLTE6gJBg3TP5LpuVvDQxZfQ5g2EX1D9sQAgc25Y6RbGGMKfH3_zpZwrBLi2X7aDMOv4KXBRXBe/s1600/expert+panel.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="146" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8nsruMNy6orO0Xe8Ch3sry7yxVENajaoUO7Z7xcWUz-EeMwQwgBEpSTr_m1P3tKUfZzLTE6gJBg3TP5LpuVvDQxZfQ5g2EX1D9sQAgc25Y6RbGGMKfH3_zpZwrBLi2X7aDMOv4KXBRXBe/s320/expert+panel.jpg" width="320" /></a><span style="font-size: 12pt;"><span style="font-family: Calibri;">Guidelines for care
increasingly help guide medical decision-making. If you’ve followed top health
news over the past several years you’ve read conflicting statements about the
utility of various medical procedures and tests. As a general internist I’ve
devoured these reports with particular interest trying to wade through bias to
formulate views that I believe will be of most benefit to my patients.</span></span></div>
<br />
<span style="font-size: 12pt;"><span style="font-family: Calibri;">Recently I put together a
talk about recommendations for prevention in women. As I prepared the talk I
sorted through the data and opinions of various medical special interest
groups.<span style="mso-spacerun: yes;"> </span>Guidelines for care are usually
developed by professional organizations or “expert panels,” such as the Center for Disease
Control (CDC), or the American Cancer Society (ACS).<span style="mso-spacerun: yes;"> </span>One might like to think of these panels as unbiased
in their advice, but clearly each expert panel is tainted, at least to a degree,
by its own special interests.<span style="mso-spacerun: yes;">
</span>Conflicting guidelines make it hard for health care consumers to figure
out who to believe.<o:p></o:p></span></span><br />
<span style="font-size: 12pt;"><span style="font-family: Calibri;"></span></span><br />
<span style="font-size: 12pt;"><span style="font-family: Calibri;">For example, several days ago
the United States Preventive Services Task Force (USPSTF) came out with its </span><a href="http://www.medpagetoday.com/MeetingCoverage/AUA/32817"><span style="color: blue; font-family: Calibri;">final guideline on
using PSA</span></a><span style="font-family: Calibri;"> for the purpose of screening for prostate cancer. The task force
recommended against using the test for screening healthy men, giving the
screening test a </span><a href="http://www.uspreventiveservicestaskforce.org/uspstf/grades.htm"><span style="color: blue; font-family: Calibri;">D level
rating</span></a><span style="font-family: Calibri;"> (not recommended). <o:p></o:p></span></span><br />
<br />
<span style="font-size: 12pt;"><span style="font-family: Calibri;">What is the </span><a href="http://www.ahrq.gov/clinic/uspstfix.htm"><span style="color: blue; font-family: Calibri;">USPSTF</span></a><span style="font-family: Calibri;">?<o:p></o:p></span></span><br />
<div>
<span style="font-size: 12pt;"><blockquote class="tr_bq">
The U.S. Preventive Services
Task Force (USPSTF), first convened by the U.S. Public Health Service in 1984,
and since 1998 sponsored by the Agency for Healthcare Research and Quality
(AHRQ), is the leading independent panel of private-sector experts in
prevention and primary care. The USPSTF conducts rigorous, impartial
assessments of the scientific evidence for the effectiveness of a broad range
of clinical preventive services, including screening, counseling, and
preventive medications. Its recommendations are considered the "gold
standard" for clinical preventive services.</blockquote>
</span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt;"><span style="font-family: Calibri;">As a general internist I was indoctrinated
to trust the USPSTF with a degree of allegiance that rivals my commitment to the
University of Michigan Wolverines (my alma mater).<span style="mso-spacerun: yes;"> </span>Nonetheless, there are other expert opinions
that I also pay attention to.<span style="mso-spacerun: yes;"> </span>In the
case of PSA screening the </span><a href="http://www.auanet.org/content/health-policy/government-relations-and-advocacy/in-the-news/uspstf-psa-recommendations.cfm?WT.mc_id=PRT6660MKT"><span style="color: blue; font-family: Calibri;">American
Urological Association</span></a><span style="font-family: Calibri;"> (AUA) continues to make a strong argument supporting
its use in screening. I discuss the debate more in my previous post:<span style="mso-spacerun: yes;"> </span></span><a href="http://www.drdialogue.com/2011/11/should-doctors-stop-using-psa-to-screen.html"><span style="color: blue; font-family: Calibri;">Should
Doctors Stop Using PSA to Screen for Prostate Cancer?</span></a><span style="font-family: Calibri;"><span style="mso-spacerun: yes;"> </span><o:p></o:p></span></span></div>
<span style="font-size: 12pt;"><span style="font-family: Calibri;">Another example of
conflicting opinions in medical guidelines:<span style="mso-spacerun: yes;">
</span>Who should be screened for diabetes?<span style="mso-spacerun: yes;">
</span>The </span><a href="http://care.diabetesjournals.org/content/35/Supplement_1/S11/T4.expansion.html"><span style="color: blue; font-family: Calibri;">American
Diabetes Association</span></a><span style="font-family: Calibri;"> (ADA) recommends that all adults with a body mass
index >25 kg/m2 (overweight or obese adults) and one additional risk factor
for diabetes be screened at least every three years, and that all adults with a
BMI>25kg/m2 who are over 45 years of age be screened. In contrast, the
USPSTF recommends for screening only </span><a href="http://www.uspreventiveservicestaskforce.org/uspstf/uspsdiab.htm"><span style="color: blue; font-family: Calibri;">adults
with blood pressure greater than 135/80</span></a><span style="font-family: Calibri;">, a grade B (recommended) rating.
For other healthy adults, overweight or not, it advises that the evidence is
insufficient to recommend for or against screening.<o:p></o:p></span></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt;"><span style="font-family: Calibri;">These are but two examples of
the numerous medical guidelines and recommendations that conflict:<span style="mso-spacerun: yes;"> </span>who should be screened for HIV, whether women
ages 40 to 50 should be screened routinely for breast cancer with mammograms, how
often women over 50 should be screened with mammograms, how often women under
30 should have a pap smear, whether women need an annual pelvic exam, whether
women need an annual breast exam, and at what age screening for colon cancer
with colonoscopy should be discontinued.<span style="mso-spacerun: yes;">
</span>The ADA, <span style="mso-spacerun: yes;"> </span>the USPSTF, the CDC, the
American College of Obstetrics and Gynecology (ACOG), the ACS, the AUA, the
American Heart Association and American College of Cardiology—along with
numerous other professional societies and expert groups have not reached
consensus on various matters.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></span></div>
<span style="font-size: 12pt;"><span style="font-family: Calibri;">Primary care doctors, as a
group, have largely been supportive of proposed measures to reduce medical “waste”—including
“unnecessary” tests and procedures that promise to bankrupt Medicare if they
continue to go unchecked. In turn we stand to benefit from proposals to
re-organize health care delivery and to strengthen primary care--the Medical Home
Model, which may channel additional funds toward primary care. In comparison to
specialists, primary care physicians have suffered in recent decades, with reimbursement
policies that favor physicians who do procedures, as opposed to those who primarily
talk to patients for a living.<span style="mso-spacerun: yes;"> </span>We have
been historically under-represented in the American Medical Association, the
largest physician’s professional group in our country. I am part of the <a href="http://www.acponline.org/about_acp/">American College of Physicians</a><span style="font-family: Times New Roman;"> (ACP), a national organization of
internists — physicians who specialize in the prevention, detection and
treatment of illnesses in adults--</span>but recognize that we also have bias—currently, in my view, a growing skepticism of tests
and procedures, which in many ways is overdue. Yet I
would wager that it’s a sentiment that primary care physicians find easier to
rally behind than do many specialists, whose interests are more likely to be
threatened by changes to reimbursement policy.</span></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt;"><span style="font-family: Calibri;">Who does one believe? Professional
guidelines are likely to shape what is covered by Medicare and private health
insurance. If you’re a gynecologist you might trust ACOG, if you’re a primary
care doctor, the USPSTF or the ACP, a urologist, the American Urological Association--the
politics of medicine are as real as the patients that we treat. Moreover, advocacy
groups, such as the Susan G. Komen Foundation and Planned Parenthood, play a
role in shaping public opinion, which no doubt can also influence the opinion
of even “expert panels,”<span style="mso-spacerun: yes;"> </span>afraid to anger
these factions.<o:p></o:p></span></span></div>
<span style="font-size: 12pt;"><span style="font-family: Calibri;">If you are a medical
professional it’s important to be aware of where guidelines conflict and to
avoid reflexively supporting one own expert panels.<span style="mso-spacerun: yes;"> </span>Even better (though more difficult), read
through the original data. If you’re a patient, sometimes it’s good to get the
opinion of both a specialist and a generalist in these matters—each can be
equally valid and it can help one see both the trees and the forest. <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt;"><span style="font-family: Calibri;"><span style="mso-spacerun: yes;"> </span><o:p></o:p></span></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<br /></div>
</div><div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com0tag:blogger.com,1999:blog-3946741689271235070.post-74332939245937166652012-04-05T13:54:00.000-07:002012-04-05T13:54:34.750-07:00Why Doctors Interrupt<div dir="ltr" style="text-align: left;" trbidi="on">
<!--[if gte mso 9]><xml>
<w:WordDocument>
<w:View>Normal</w:View>
<w:Zoom>0</w:Zoom>
<w:TrackMoves/>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:DoNotPromoteQF/>
<w:LidThemeOther>EN-US</w:LidThemeOther>
<w:LidThemeAsian>X-NONE</w:LidThemeAsian>
<w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:SnapToGridInCell/>
<w:WrapTextWithPunct/>
<w:UseAsianBreakRules/>
<w:DontGrowAutofit/>
<w:SplitPgBreakAndParaMark/>
<w:DontVertAlignCellWithSp/>
<w:DontBreakConstrainedForcedTables/>
<w:DontVertAlignInTxbx/>
<w:Word11KerningPairs/>
<w:CachedColBalance/>
<w:UseFELayout/>
</w:Compatibility>
<w:DoNotOptimizeForBrowser/>
<m:mathPr>
<m:mathFont m:val="Cambria Math"/>
<m:brkBin m:val="before"/>
<m:brkBinSub m:val="--"/>
<m:smallFrac m:val="off"/>
<m:dispDef/>
<m:lMargin m:val="0"/>
<m:rMargin m:val="0"/>
<m:defJc m:val="centerGroup"/>
<m:wrapIndent m:val="1440"/>
<m:intLim m:val="subSup"/>
<m:naryLim m:val="undOvr"/>
</m:mathPr></w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="true"
DefSemiHidden="true" DefQFormat="false" DefPriority="99"
LatentStyleCount="267">
<w:LsdException Locked="false" Priority="1" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Normal"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="heading 1"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 2"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 3"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 4"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 5"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 6"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 7"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 8"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 9"/>
<w:LsdException Locked="false" Priority="39" Name="toc 1"/>
<w:LsdException Locked="false" Priority="39" Name="toc 2"/>
<w:LsdException Locked="false" Priority="39" Name="toc 3"/>
<w:LsdException Locked="false" Priority="39" Name="toc 4"/>
<w:LsdException Locked="false" Priority="39" Name="toc 5"/>
<w:LsdException Locked="false" Priority="39" Name="toc 6"/>
<w:LsdException Locked="false" Priority="39" Name="toc 7"/>
<w:LsdException Locked="false" Priority="39" Name="toc 8"/>
<w:LsdException Locked="false" Priority="39" Name="toc 9"/>
<w:LsdException Locked="false" Priority="35" QFormat="true" Name="caption"/>
<w:LsdException Locked="false" Priority="10" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Title"/>
<w:LsdException Locked="false" Priority="1" Name="Default Paragraph Font"/>
<w:LsdException Locked="false" Priority="11" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" Priority="22" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" Priority="59" SemiHidden="false"
UnhideWhenUsed="false" Name="Table Grid"/>
<w:LsdException Locked="false" UnhideWhenUsed="false" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" UnhideWhenUsed="false" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" QFormat="true" Name="TOC Heading"/>
</w:LatentStyles>
</xml><![endif]--><!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-priority:99;
mso-style-qformat:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin-top:0in;
mso-para-margin-right:0in;
mso-para-margin-bottom:10.0pt;
mso-para-margin-left:0in;
mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:"Calibri","sans-serif";
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
</style>
<![endif]-->
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiji1gFyOVW-wJptT-nnFXCUq-DTVBx3hdO22rDnYSRblpziOaVb5d1gx4N3SOhRKqhdRPrc-s76lJKW52kXcs1HlpW8HW9N3o1vfguXd-F-2dSrGur-eJ-RcLKbbLgDjtcEbUoxh2y08g0/s1600/house+with+bandaids.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiji1gFyOVW-wJptT-nnFXCUq-DTVBx3hdO22rDnYSRblpziOaVb5d1gx4N3SOhRKqhdRPrc-s76lJKW52kXcs1HlpW8HW9N3o1vfguXd-F-2dSrGur-eJ-RcLKbbLgDjtcEbUoxh2y08g0/s1600/house+with+bandaids.jpg" /></a></div>
<div class="MsoNormal">
A few weeks ago I called a neurosurgeon to discuss a patient’s
recent headaches.<span style="mso-spacerun: yes;"> </span>My patient had been
seen in the emergency room several days prior with the worst headache of his
life. A complete work-up had not revealed a cause for the headache.<span style="mso-spacerun: yes;"> </span>Although he was found to have a small aneurysm
on CT angiogram, there was no evidence of bleeding by lumbar puncture.<span style="mso-spacerun: yes;"> </span>The story, however, was slightly more complex
than this. There had been several other findings that remained unexplained. <span style="mso-spacerun: yes;"> </span>One of the findings led me to discuss the
patient’s case with a cardiologist.<span style="mso-spacerun: yes;"> </span>My
patient had also undergone cervical spine decompression surgery several months
prior to treat cervical myelopathy. <span style="mso-spacerun: yes;"> </span>I
wanted to engage the neurosurgeon and get his professional opinion about my
patient’s headache, which had now recurred several days after his ER visit.</div>
<div class="MsoNormal">
The surgeon was cordial, but about 5 seconds into my story
he seemed inpatient and interrupted me.<span style="mso-spacerun: yes;"> </span>“I
heard about this guy,” he said, “What he needs is to be seen by one of our
neurovascular specialists.”<span style="mso-spacerun: yes;"> </span>I had more I
wanted to say, but the doctor did not seem to want to listen.<span style="mso-spacerun: yes;"> </span>I raised my voice slightly, interrupted him before
he had a chance to end the conversation, and bulldozed through, telling the rest of the
story in about two minutes.<span style="mso-spacerun: yes;"> </span>“Now we’re
talking,” he said, as I explained further about a family history of clotting
and my concern about a dural thrombus as a potential etiology.<span style="mso-spacerun: yes;"> </span>Together we formulated a plan that I was satisfied with--though the interaction
left me with a feeling of unease. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Interruption is a pervasive communication style with
doctors. <span style="mso-spacerun: yes;"> </span>In a well known study by
<a href="http://www.ncbi.nlm.nih.gov/pubmed/6486600">Beckman and Frankel</a> patients were allowed to complete their opening statement
expressing their agenda in its entirety in only 23% of physician interviews.<span style="mso-spacerun: yes;"> </span>The average time to interruption was 18
seconds.<span style="mso-spacerun: yes;"> </span>This study’s findings have been
replicated by several others.<span style="mso-spacerun: yes;"> </span>In a more recent study of<a href="http://www.ncbi.nlm.nih.gov/pubmed/11456245"> primary care residents</a>, patients were allowed to speak for only 12 seconds on
average before they were interrupted.<span style="mso-spacerun: yes;">
</span>Female patients experience interruption more frequently than males. In
contrast, studies have suggested <a href="http://interruptions.net/literature/Rowland-Morin-EvalHealthProf90.pdf%20">higher rates of patient satisfaction</a> with physician
visits during which patients and doctors interrupt at similar frequency and
also with visits in which there is more “reflective” silent time during the
conversation. <span style="mso-spacerun: yes;"></span>Perhaps the tendency to interrupt extends to all physician derived professional
communications, as in my case with the neurosurgeon on the phone.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Why do physicians interrupt?<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>In practical terms, throughout
the course of a given day a physician may be tasked with listening to twenty to
thirty patient derived histories and with solving difficult problems for each
of these patients in a matter of ten to fifteen minutes.<span style="mso-spacerun: yes;"> </span>This is a tough, if not impossible job.<span style="mso-spacerun: yes;"> </span>Consequently, once a physician believes that the
meat of the story is out there, he or she may respond and interrupt before
hearing details that the patient (or colleague) feels are important.<span style="mso-spacerun: yes;"> </span>In more abstract terms interruption is a
communication strategy that reinforces physician dominance in the hierarchy of
the patient-physician relationship.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The most frequent complaint that I hear from patients about
other physicians is that a physician did not “listen,” or did not “seem to care”
about their problem.<span style="mso-spacerun: yes;"> </span>My advice to
physicians and medical trainees: sit down, bite your tongue and wait. If you do
interrupt, do so with brief questions allowing your patient to return to his or
her agenda.<span style="mso-spacerun: yes;"> </span>You might be surprised and learn
something, and no doubt you’ll certainly have happier patients (and
colleagues).</div>
</div><div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com1tag:blogger.com,1999:blog-3946741689271235070.post-62408215132613772882012-03-19T10:18:00.000-07:002012-03-19T10:18:31.113-07:00Who Should Take Aspirin for Prevention?<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgiwsrFeuhOhGZ4x7ieFAdX68jL_oVHx4kItCLcICgORJ3J4rX7GOoKQq1p_YQvyWbx1_15fhyphenhyphennv6GFsBeiuMiqWn95fQ-O1dBDnzbttCsXzmZfwrLr_pGeokbIL8Y9WAaqXsS9BlezqyE3/s1600/aspirin.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgiwsrFeuhOhGZ4x7ieFAdX68jL_oVHx4kItCLcICgORJ3J4rX7GOoKQq1p_YQvyWbx1_15fhyphenhyphennv6GFsBeiuMiqWn95fQ-O1dBDnzbttCsXzmZfwrLr_pGeokbIL8Y9WAaqXsS9BlezqyE3/s1600/aspirin.jpg" /></a></div>
<span style="font-family: Calibri;">The answer is not entirely straightforward.<span style="mso-spacerun: yes;"> </span>Aspirin has been shown to reduce the risk of cardiovascular
disease, including heart attack and stroke. Aspirin inhibits the function of
platelets, the blood cell line responsible for clot formation.<span style="mso-spacerun: yes;"> </span>When a heart attack or stroke occur the cholesterol
plaque that lines an artery ruptures and platelets aggregate, resulting in a
cascade that results in acute occlusion of a blood vessel.<span style="mso-spacerun: yes;"> </span>Patients who are treated with aspirin are
less likely to clot.<span style="mso-spacerun: yes;"> </span>However, the
effects of aspirin are not entirely benign. With its platelet inhibition it
also confers a higher risk of bleeding—in particular gastrointestinal bleeding
and hemorrhagic stroke, </span><span style="font-family: Calibri;">which also may be life threatening.</span><br />
<div style="text-align: left;">
</div>
<div style="text-align: left;">
<span style="font-family: Calibri;">Clinical trials have looked at aspirin intake,
cardiovascular outcomes, and bleeding risk. Aspirin for acute cardiovascular
events and for “secondary prevention” (prevention after the diagnosis of
coronary artery disease or cerebrovascular disease has been established) is
undisputed.<span style="mso-spacerun: yes;"> </span>Trials suggest that the
benefits of therapy outweigh the risks of bleeding.<span style="mso-spacerun: yes;"> </span></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">However, whether or not aspirin should be prescribed for
“primary prevention” (prevention in a person who is disease-free) is more
ambiguous.<span style="mso-spacerun: yes;"> </span>In 2009 a meta-analysis of
existing study data looking at this question was published in <a href="http://www.ncbi.nlm.nih.gov/pubmed/19482214?dopt=Abstract">Lancet</a>. </span><span style="font-family: Calibri;">
<span style="mso-spacerun: yes;"> </span>The analysis found that aspirin reduced
the risk of non-fatal myocardial infarction by one fifth, but that aspirin
therapy also significantly increased risk of major gastrointestinal and
extracranial bleeding and did not improve overall mortality. <span style="mso-spacerun: yes;"> </span>In 2009 the US Preventive Services Task Force (USPSTF)
reviewed the existing data and concluded that while aspirin reduces the risk of
myocardial infarction in men and ischemic stroke in women, it increases the
risk of major extracranial bleeding.<span style="mso-spacerun: yes;"> </span>The
<a href="http://www.ncbi.nlm.nih.gov/pubmed/19293073">USPSTF recommended</a> that the decision to use aspirin therapy for the purpose of
primary prevention should take into account an individualized assessment of cardiovascular
risk and also bleeding risk. Patients with higher cardiovascular risk may
benefit most from therapy. </span><span style="mso-spacerun: yes;"><span style="font-family: Calibri;"> </span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Patients considering aspirin therapy for primary prevention
should assess their cardiovascular risk profile with their personal physician.
The <a href="http://hp2010.nhlbihin.net/atpiii/calculator.asp">Framingham Risk Calculator</a> is a recommended tool for estimating one’s ten
year risk of having a major cardiovascular event. <span style="mso-spacerun: yes;"> </span></span><span style="font-family: Calibri;">
However, Framingham may not be as useful for women as it is for men, and some
recommend use of the <a href="http://www.reynoldsriskscore.org/">Reynolds Risk Calculator</a>. The Reynolds Calculator incorporates
the inflammatory marker <a href="http://www.drdialogue.com/2011/10/screening-for-inflammation-with-hscrp.html">hs-crp</a> into its calculation of ten year risk. </span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">In a similar vein, in 2010 the American Diabetes Association,
the American Heart Association, and the American College of Cardiology issued a
<a href="http://www.theheart.org/article/1085451.do">joint statement revising their recommendations for use of aspirin for thepurpose of primary prevention amongst diabetic patients</a>.<span style="mso-spacerun: yes;"> </span>In contrast to old guidelines, the new
recommendations do not advise that all diabetics over age 40 receive aspirin
therapy. <span style="mso-spacerun: yes;"> </span>Rather, they advise aspirin therapy
for primary prevention in male diabetics under 50 and female diabetics under 60
only if one additional cardiac risk factor is present (hypertension, high
cholesterol, smoking, family history, microalbuminuria) </span><span style="font-family: Calibri;">
The new recommendation is based in part on a subgroup analyses of diabetic
patients in the meta-analysis of the Antithrombotic Trialists’ Collaboration showing
<span style="mso-spacerun: yes;"> </span>that diabetic patients benefited less from
aspirin therapy than non-diabetics. In addition, several smaller studies
conducted specifically on diabetics and looking at primary prevention failed to
demonstrate a significant benefit of aspirin therapy in those without diagnosed
cardiovascular disease.<span style="mso-spacerun: yes;"> </span>Further study is
ongoing to research the issue of primary prevention of cardiovascular disease
with aspirin in diabetic patients.<span style="mso-spacerun: yes;"> </span>For
now the therapy is recommended for diabetics who are determined to be
intermediate to high risk (Framingham risk of 10% or higher).</span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Who is most likely to suffer a complication related to daily
use of aspirin? <a href="http://www.isdbweb.org/app/webroot/documents/file/1449_10.pdf">Risk factors for gastrointestinal bleeding</a> with aspirin therapy
have been identified:</span></div>
<ul style="text-align: left;">
<li>
<span style="font-family: Calibri;">Non-steroid anti-inflammatory
(NSAID) use (in particular, high dose NSAID use)</span></li>
<li><span style="font-family: Calibri;">Chronic steroid
use</span></li>
<li><span style="font-family: Calibri;">Prior history of
peptic ulcer disease (PUD)</span></li>
<li><span style="font-family: Calibri;">Advanced age (>60-65 years old)</span></li>
<li><span style="font-family: Calibri;">GERD or dyspepsia (less risk than PUD)</span></li>
<li><span style="font-family: Calibri;">Concomitant use of another anti-coagulant</span></li>
</ul>
<span style="font-family: Calibri;">Treatment with a proton pump inhibitor, or the prostaglandin
E analog misoprostol, can reduce one’s risk of gastrointestinal bleeding from
NSAIDS.<span style="mso-spacerun: yes;"> </span>By contrast, H2 blockers are not
effective in this regard.<span style="mso-spacerun: yes;"> </span>In addition, using
enteric coated aspirin does not reduce its gastrointestinal toxicity.<span style="mso-spacerun: yes;"> </span>It is unclear what dose of aspirin is best for
primary prevention, but most recommend low dose aspirin (81-162mg), which
appears to be equal in efficacy to higher doses (though it has not been
demonstrated to be safer).</span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><em>It’s interesting to
me that simultaneous with a growing emphasis on incorporating population-based
strategies into healthcare delivery we are also becoming increasingly aware of
the importance of identifying personalized risk factors in order to best counsel
individual patients on medical care and prevention.<span style="mso-spacerun: yes;"> </span>Aspirin therapy for primary prevention is an
example of how a one-size-fits-all population-based strategy is hard to
apply.<span style="mso-spacerun: yes;"> </span>We have seen similar recent
trends with mammography screening recommendations, using PSA for prostate
cancer screening, and will likely soon be hearing more about using a personalized
approach to recommending statins for the purpose of primary prevention of
cardiovascular disease (given recent associations between statin use and reversible
cognitive complaints and diabetes). How population medicine, its associated
quality reporting, and pay-for-performance on the one hand, and personalized
medicine on the other, are reconciled in medical practice will be a challenge to
be dealt on the level of policy, practice, and reimbursement in years to come.</em></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<br /></div>
</div><div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com4tag:blogger.com,1999:blog-3946741689271235070.post-34052602388959222582012-01-31T04:54:00.000-08:002012-01-31T16:24:16.316-08:00Intuitive Eating and More<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhGD53QUoGdu9htljTsUTwJiwwOO1YlSy_YJYozpF9C4XoL0y025s49KGazxX-9QlirdUaWJ7jpWJAslKp6njKGTstA-tUQr98i5OHC1Z_ZERjD_dxujZuIJysKIqBModEVfAyvqynTCbg2/s1600/318.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhGD53QUoGdu9htljTsUTwJiwwOO1YlSy_YJYozpF9C4XoL0y025s49KGazxX-9QlirdUaWJ7jpWJAslKp6njKGTstA-tUQr98i5OHC1Z_ZERjD_dxujZuIJysKIqBModEVfAyvqynTCbg2/s320/318.JPG" width="320" /></a><span style="font-family: Calibri;">Recently Personalized Primary Care Atlanta hosted an evening
workshop reviewing some of today’s popular diets.<span style="mso-spacerun: yes;"> </span>Nutritionist, <a href="http://tdwellness.com/about-us.html">David Orozco</a>, RD </span><span style="font-family: Calibri;"><span style="mso-spacerun: yes;"> </span>presented an overview of popular diets
including: Atkins, South Beach, Paleo, Sugar Busters, DASH, Mediterranean,
Zone, Weight Watcher’s, and the HCG diet, among others.<span style="mso-spacerun: yes;"> </span></span></div>
<br />
<span style="font-family: Calibri;">In his talk Mr. Orozco briefly described some key
elements of “fad” diets to beware of: </span><br />
<ul style="text-align: left;">
<li><span style="font-family: Calibri;">A magic bullet (i.e. the hormone HCG, which,
when given with a 500 kcal per day diet, results in weight loss)</span></li>
<li><span style="font-family: Calibri;">Diet phases or stages, such as “Rapid Detox” and
“Maintenance” phases</span></li>
<li><span style="font-family: Calibri;">Celebrity testimonials and endorsements</span></li>
</ul>
<span style="font-family: Calibri;">Medical professionals agree that the <a href="http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf">DASH diet</a> </span><span style="font-family: Calibri;">
and the <a href="http://www.webmd.com/food-recipes/news/20110307/mediterranean-diet-lowers-risk-of-metabolic-syndrome">Mediterranean diet</a> have the most scientific evidence to back up their potential
benefit in terms of health related outcomes such as hypertension and metabolic
syndrome. </span><span style="font-family: Calibri;">
These two diets are also ranked #1 and #2 respectively by a <a href="http://health.usnews.com/best-dietWebMD">US News ranking</a> of "Best Diets."<span style="mso-spacerun: yes;"> </span><a href="http://www.webmd.com/diet/evaluate-latest-diets">WebMD’s diet comparison tool</a> comes very highly recommended if you are sorting through diet options.</span><br />
<br />
<span style="font-family: Calibri;">However, Mr. Orozco advocates a
different approach to dieting: “<a href="http://www.intuitiveeating.org/content/what-intuitive-eating">Intuitive Eating</a>,” or “<a href="http://www.amazon.com/Mindful-Eating-Rediscovering-Relationship-Food--/dp/1590305310/ref=sr_1_1?ie=UTF8&qid=1326910495&sr=8-1">Mindful Eating</a>.” These concepts</span><span style="font-family: Calibri;"> </span><span style="font-family: Calibri;">involve gaining an understanding of one’s relationship with food and then healing
it, such that an individual gains a heightened responsiveness to his or her own
body signals.<span style="mso-spacerun: yes;"> </span>The premise, a kind of psychotherapeutic
approach, is that intuitive eating will result in better food equilibrium and
eventual healthy weight maintenance. <span style="mso-spacerun: yes;"> </span>I’ll
admit that I have not yet read the book, but am eager to do so.</span><br />
<br />
<span style="font-family: Calibri;"> As I listened to the talk, I
brought to the table my own perspective—I have never struggled
with my weight, I am a relatively compulsive exerciser, and I enjoy
cooking and eating out.<span style="mso-spacerun: yes;"> </span>Exercise alone has been shown
to be an effective technique to help with weight
maintenance.<span style="mso-spacerun: yes;"> </span>My personal experience
(I’ve been about the same weight since age 18) is testimony to this. However, the
one time that I did lose 15 pounds, I did it through calorie counting.<span style="mso-spacerun: yes;"> </span>Since then (twenty years ago), I’ll admit
that I do have a conscious awareness of the caloric value of most food that I
ingest.<span style="mso-spacerun: yes;"> </span>Do I eat chips, chocolate, an
occasional Quarter Pounder and fries? Absolutely; but when the scale tips up
five pounds I am quick to take action and cut back.<span style="mso-spacerun: yes;"> </span>For dinner tonight—homemade lentil soup with
kielbasa, bacon, and carrots, brown rice, green salad with blue cheese, and a
glass of Argentine Malbec; for dessert: a
sliver of lemon pound cake topped with coconut gelato.</span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">I have found that with my patients who want to achieve more
than ten pounds of weight loss, a structured approach is essential—a specific <b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;">action
plan</i></b>.<span style="mso-spacerun: yes;"> </span>Vague plans to cut back
and “eat healthier” tend not to be effective.<span style="mso-spacerun: yes;"> Over the years I have asked my patients who have successfully lost weight what their strategy was. Though the strategies that my patients describe are as diverse as are the array of diets on the market, a common thread seems that those who have been successful are able to <strong><em>articulate a clear plan of action </em></strong>that led to the weight loss.
</span></span><br />
<br />
<span style="font-family: Calibri;">I am an advocated of calorie counting and Weight Watchers (whose point
system is essentially like calorie counting).<span style="mso-spacerun: yes;">
</span>My viewpoint is that for weight loss, it’s not so much the content of
the food that matters, but rather the quantity and caloric value.<span style="mso-spacerun: yes;"> </span>However, there is some evidence that <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa0708681">low carbohydrate diets</a> may produce more weight loss than very low fat diets (i.e. the
Ornish Diet) though this finding has not yet been definitively proven. A pound
of fat is equal to 3500 kcal. It’s hard to lose more than a pound of fat every
7 to 10 days, and I don’t recommend it.<span style="mso-spacerun: yes;">
</span>I personally consume about 2000-2500 kcal per day (with 30-60 minutes of
exercise on most days). </span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Here are some of my own weight loss tips:<span style="mso-spacerun: yes;"> </span></span></div>
<ul style="text-align: left;">
<li>
<span style="font-family: Calibri;">Eat smaller portions, but don’t skip meals</span></li>
<li>
<span style="font-family: Calibri;">Count and record your calories for at least 1-2 weeks when
you begin to diet</span></li>
<li>
<span style="font-family: Calibri;">Don’t reduce your caloric intake by more than 500 kcal per
day below baseline intake (it’s too hard to maintain)</span></li>
<li>
<span style="font-family: Calibri;">Don’t drink diet drinks and don’t drink any beverage all day
long (including water)</span></li>
<li>
<span style="font-family: Calibri;">Do have coffee or tea following a meal if you are not quite
satisfied</span></li>
<li>
<span style="font-family: Calibri;">Do enjoy a mealtime ritual at least once a day-- set the
table and play some music while you dine, enjoy your oatmeal and coffee while
reading the paper</span></li>
<li>
<span style="font-family: Calibri;">Don’t snack more than once per day</span></li>
<li>
<span style="font-family: Calibri;">Do allow yourself to feel hunger for a couple of hours
before you eat</span></li>
<li>
<span style="font-family: Calibri;">Limit refined carbohydrates and add healthy fats, but forget
margarine, it’s no substitute for butter </span></li>
<li>
<span style="font-family: Calibri;">Don’t eliminate your favorite food, save it as a treat a day
or two per week</span></li>
<li>
<span style="font-family: Calibri;">Treat yourself to
meals out, but split your portion with a companion or eat an appetizer instead
of an entree</span></li>
<li>
<span style="font-family: Calibri;">Exercise 3-4 times per week, but keep in mind that adding
exercise alone rarely works to achieve more than 5 to 10 pounds of weight loss<span style="mso-spacerun: yes;"> </span></span></li>
<li>
<span style="font-family: Calibri;">Don’t chastise yourself if you are unable to exercise, most
of weight loss comes through alterations in one’s diet not through exercise</span></li>
<li>
<span style="font-family: Calibri;">Cook at least three times per week using whole food
ingredients and cook enough for two meals so that you can have leftovers</span></li>
<li>
<span style="font-family: Calibri;">Pack your lunch and bring it to work</span></li>
</ul>
<span style="font-family: Calibri;">Once your desired weight loss is reached, this is where intuitive
or mindful eating becomes important—retraining oneself toward a healthier relationship
with food.<span style="mso-spacerun: yes;"> </span>Weight maintenance is the
hard part. Some of you may have read a recent New York Times Magazine cover article
entitled “<a href="http://www.nytimes.com/2012/01/01/magazine/tara-parker-pope-fat-trap.html?_r=1&pagewanted=all">The Fat Trap</a>” by weekly health columnist and author of the NYT "Well" blog Tara Parker-Pope.<span style="mso-spacerun: yes;"> </span></span><span style="font-family: Calibri;">Ms. Parker-Pope makes the case that powerful metabolic and hormonal factors
make it very difficult to maintain weight loss.<span style="mso-spacerun: yes;">
</span>I personally find Ms. Parker-Pope’s viewpoint overly nihilistic, though
she brings to light interesting information. <span style="mso-spacerun: yes;"> </span><a href="http://www.ipetitions.com/petition/response-to-nytimes-the-fat-trap/">A petitioned response</a> to Ms. Parker-Pope’s
piece, authored </span><span style="font-family: Calibri;">Gary Taubes and Peter Attia, MD, argues that Ms. Parker-Pope’s
article neglected the important effect of insulin resistance on obesity.<span style="mso-spacerun: yes;"> </span>The authors maintain that restriction of
refined carbohydrates, as opposed to overall caloric restriction, can allow
overweight patients to successfully bypass some of the metabolic impediments to
weight loss by reducing insulin resistance, while all the while suppressing
hunger through increased protein and fat consumption.<span style="mso-spacerun: yes;"> </span>Indeed there is <a href="http://www.annals.org/content/140/10/778.short">some medical evidence to support low carbohydrate diets</a>. </span><span style="font-family: Calibri;">
</span><br />
<br />
<span style="font-family: Calibri;">In my own practice I have seen numerous
patients lose weight successfully.<span style="mso-spacerun: yes;"> </span>The metabolic
effects on cholesterol, blood sugar and blood pressure are typically profound. <span style="mso-spacerun: yes;"> </span><b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;">Remember, if you are overweight or obese,
weight loss in itself is as important of a goal as is healthy eating. </i></b></span><br />
<br />
<span style="font-family: Calibri;">How did you lose weight? Were you able to maintain it? What
do you think of the intuitive eating concept? I welcome you to share your own
lessons and help others.<span style="mso-spacerun: yes;"> </span></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">*<i style="mso-bidi-font-style: normal;"><span style="font-size: x-small;">To learn more about
intuitive eating contact David Orozco RD of T+D Wellness in Atlanta at 404-228-9704.</span></i></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<br /></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<br /></div>
</div><div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com2tag:blogger.com,1999:blog-3946741689271235070.post-55769767305021274302012-01-09T04:32:00.000-08:002012-01-09T04:32:21.795-08:00When is unneeded care criminal?<div dir="ltr" style="text-align: left;" trbidi="on">
<i style="mso-bidi-font-style: normal;"><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;">Co-Authored
by Juliet K. Mavromatis, MD, FACP, Personalized Primary Care Atlanta and </span><a href="http://medicine.emory.edu/divisions/cardiology/research/ECCRI/ECCRI_Faculty/ECCRI_Mavromatis/index.cfm"><span style="color: blue; font-family: Calibri;">Kreton
Mavromatis, MD</span></a><span style="font-family: Calibri;">, Assistant Professor of Medicine, Emory University, Director
of the Cardiac Catheterization Laboratory, Atlanta VA Medical Center<o:p></o:p></span></span></i><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgw36CRb5vjmmJqtoP7Uu40ujkVMacuSK844EyFbxlT0NUAr7pqxqAAF3hNOPIVcp4n0KOyDvAAg3Yc9RKelJ-pGLK6s2_5-UOxLXL7NcL9T7mPyhU1Ae9Xkr5-SGmt9oD4s0EV7Zw5oLcl/s1600/stent.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="236" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgw36CRb5vjmmJqtoP7Uu40ujkVMacuSK844EyFbxlT0NUAr7pqxqAAF3hNOPIVcp4n0KOyDvAAg3Yc9RKelJ-pGLK6s2_5-UOxLXL7NcL9T7mPyhU1Ae9Xkr5-SGmt9oD4s0EV7Zw5oLcl/s320/stent.jpg" width="320" /></a></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;">Recent media coverage has sensationalized the criminal
investigation of several cardiologists for the possibility of performing fraudulent
cardiac procedures.<span style="mso-spacerun: yes;"> </span>Is this a case of individuals
with unethical conduct? Or, does it point toward a more systemic problem in
medical care, where </span><a href="http://www.nytimes.com/2011/08/23/opinion/cut-medicare-help-patients.html?_r=2&pagewanted=all"><span style="color: blue; font-family: Calibri;">Medicare
dollars are wasted on unneeded care</span></a><span style="font-family: Calibri;">? </span></span><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;">As reported in </span></span><a href="http://www.theheart.org/article/1257637.do"><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="color: blue; font-family: Calibri;">Heartwire</span></span></a><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;">
on July 27, 2011: </span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><em>"A federal jury convicted McLean, 59, on six charges
of healthcare fraud relating to insurance claims he'd filed for stents deemed
to have been placed <b style="mso-bidi-font-weight: normal;"><u>unnecessarily</u></b>, as well as for ordering unnecessary tests
and making false entries in patient medical records…evidence brought forward
suggested that McLean had performed cardiac catheterizations and implanted <b style="mso-bidi-font-weight: normal;"><u>unnecessary</u></b>
cardiac stents in more than 100 patients. <span style="mso-spacerun: yes;"> </span>He then falsely recorded in the patients'
medical records the existence or extent of coronary artery blockage, known as
lesions, observed during the procedures in order to justify the stent and the
submission of claims to healthcare benefit programs, including <span style="mso-bidi-font-weight: bold;">Medicare</span> and <span style="mso-bidi-font-weight: bold;">Medicaid</span>."</em> </span></div>
<span style="font-family: Calibri;"></span><span style="font-family: Calibri;"><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;">In </span><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">a
separate case </span><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;">the Senate Finance
Committee </span></span><a href="http://www.theheart.org/article/1086351.do"><span style="color: blue;"><span style="font-family: Calibri;"><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">investigated
</span><span style="mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;">Dr. Mark Midei,</span></span></span></a><span style="font-family: Calibri;"><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;"> an interventional cardiologist practicing in Towson
Maryland</span><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">,</span><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;"> for
the possibility of performing <b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><u>unnecessary</u></i></b> stents and also
for his relationship with Abbott Laboratories, the company that manufactures
the stents that he used. <o:p></o:p></span></span><br />
<span style="font-family: Calibri;"><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;">A prominent cardiologist</span><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">
commented in </span></span><a href="http://www.nytimes.com/2010/12/06/health/06stent.html"><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="color: blue; font-family: Calibri;">the New
York Times</span></span></a><span style="font-family: Calibri;"><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"> report:<span style="mso-spacerun: yes;"> </span></span></span><br />
<br />
<span style="font-family: Calibri;"><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-spacerun: yes;"></span><em>“</em></span><em><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;">What was going on in Baltimore is going on rig</span><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">ht
now in every city in America,</span><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;">” </span><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">saying
that </span></em><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;"><em>he routinely treats patients who
have been given multiple unneeded stents. “We’re spending a fortune as a
country on procedures that people <b style="mso-bidi-font-weight: normal;"><u>don’t need.”</u></b></em> <o:p></o:p></span></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;">Coronary artery disease affects a large proportion of people in
Western civilization. The disease manifests as blockages in coronary arteries limiting
blood flow to heart muscle, causing heart pain, heart<span style="mso-spacerun: yes;"> </span>attacks, heart failure and/or sudden death.
Heart disease kills 1 out of every 6 Americans. Coronary artery stents are metal
mesh tubes that can be placed in blocked coronary arteries completely reopening
them and improving blood flow to the heart muscle.<span style="mso-spacerun: yes;"> </span>Many studies (</span><a href="http://www.ncbi.nlm.nih.gov/pubmed/8433725?dopt=Abstract"><span style="color: blue; font-family: Calibri;">PAMI</span></a><span style="font-family: Calibri;">, </span><a href="http://www.nejm.org/doi/full/10.1056/NEJM200106213442501"><span style="color: blue; font-family: Calibri;">TACTICS-TIMI 18</span></a><span style="font-family: Calibri;">,
etc.) have shown that when used appropriately, stents can be life-saving and
improve quality of life by relieving heart pains (angina) and preventing heart
attacks.</span></span></div>
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;">However, in 2007 the </span></span><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa070829"><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="color: blue; font-family: Calibri;">COURAGE</span></span></a><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;"><span style="mso-spacerun: yes;"> </span>trial was published demonstrating that in <i style="mso-bidi-font-style: normal;"><u>some</u></i> patients with coronary
artery disease, there was no mortality or heart attack benefit associated with
an initial treatment strategy of using stents, compared<span style="mso-spacerun: yes;"> </span>with medication treatment.<span style="mso-spacerun: yes;"> </span>The trial also found evidence that a strategy
of using medications alone could potentially save money. In considering these
results, several caveats must be kept in mind: patients included in the study
were very select (< 1 in 15 patients considered were actually studied); they
tended to have mild disease (78% had either no or only slight symptoms;
patients with recent heart attacks were excluded);<span style="mso-spacerun: yes;"> </span>~1/3 of patients initially treated with medications
alone eventually required stents for their blockages anyway.<span style="mso-spacerun: yes;"> </span>In addition, patients who underwent initial treatment
with stents had a quicker improvement in quality of life as compared to
patients who initially were treated with medications alone. Nonetheless, this single
study suggested that the need for coronary stenting is <b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><u>unnecessary</u></i></b> in at
least some patients with coronary artery disease, and that trying medication therapy
alone in those patients is reasonable. There is ongoing investigation designed
to confirm or refute the observations of the COURAGE trial.<o:p></o:p></span></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;">In a New York Times editorial entitled </span><a href="http://www.nytimes.com/2011/08/23/opinion/cut-medicare-help-patients.html?pagewanted=all"><span style="color: blue; font-family: Calibri;">Cut
Medicare, Help Patients</span></a><span style="font-family: Calibri;"> authors Ezekiel Emanuel and Jeffrey Liebman discuss
the use of cardiac stents for treatment of symptomatic coronary artery disease suggesting
that many stents are <b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><u>unneeded.</u></i></b></span></span><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.5pt; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;"> </span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.5pt; mso-bidi-theme-font: minor-latin;">“<em>Every year more than 1
million cardiac stents are placed in patients to open blocked arteries…</em></span><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><em> </em></span><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.5pt; mso-bidi-theme-font: minor-latin;"><em>many patients who receive stents paid for by Medicare
are either experiencing no pain or have not tried medication first.”</em> </span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;">In a review of national registry data published this year in </span><a href="http://unnecessary-stent.com/images/Inappropriate_Stenting_JAMA_2011.pdf"><span style="color: blue; font-family: Calibri;">JAMA
by Chan et al.</span></a><span style="font-family: Calibri;"> it was concluded that by current criteria 1 to 11.6 percent of
stents placed may have been “<b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><u>inappropriate</u></i></b>” based in part
on the results of the COURAGE study. <span style="mso-spacerun: yes;"> </span></span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;">It is important to distinguish between “unneeded care” due to
fraud and “unneeded care” due to less expensive but similarly effective
alternatives. Fraud implies dishonest intent. Unneeded care due to fraud is
universally considered to be wrong. In contrast, calling care unneeded because
there are less expensive and similarly effective alternatives is subject to a broad
range of opinion. In an article that I read recently </span><a href="http://www.theheart.org/article/1323479.do?utm_campaign=newsletter&utm_medium=email&utm_source=20120103_topTen"><span style="color: blue; font-family: Calibri;">Dr.
Maneesh Patel </span></a></span><span style="color: black; font-family: "Arial","sans-serif";"><span style="mso-spacerun: yes;"> </span></span><span style="font-family: Calibri;"><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">(Duke
Clinical Research Institute, Durham, NC) made the important point: </span></span></div>
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">"<em>the
majority of what we do in medicine is based on evidence that would fall into
the category of 'uncertain' "—for example, guideline recommendations with
level of evidence B or C.</em></span><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><em>“</em> </span></span></div>
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;">The Maryland cardiologists are accused fraud, or falsely recording
the presence of significant coronary artery disease, and billing health insurance
for placing stents in such patients. This is very different than choosing to
treat significant coronary artery disease with a stent when medical therapy
alone may also be a reasonable strategy in preventing death or myocardial
infarction (heart attack).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></span></div>
<br />
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;">Here’s an example:<span style="mso-spacerun: yes;"> </span>a 50
year old man was found to have calcifications in his coronary arteries on a
chest CT done for follow up of cancer (presumed cured). On questioning, the
patient, who has high blood pressure, high cholesterol, and a family history of
heart disease, noticed some shortness of breath with exertion, potentially due
to obstructive coronary artery disease.<span style="mso-spacerun: yes;">
</span>An exercise treadmill test was ordered and was positive after ten
minutes.<span style="mso-spacerun: yes;"> </span>An exercise echocardiogram was
ordered and showed a possible small area of reduced blood flow after ten
minutes.<span style="mso-spacerun: yes;"> </span>A cardiac catheterization was
ordered and an 80 percent blockage of one artery was found. A stent was placed
and the patient was started on blood thinners.<span style="mso-spacerun: yes;">
</span>The patient also had 30 to 50 percent blockages in other locations and
was advised to take more cholesterol and blood pressure medication.<o:p></o:p></span></span><br />
<br />
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;">Which of the tests/treatments in this case were unnecessary? If
the coronary blockage was 40 percent and not 80 percent, the stenting here
would be universally considered to be unnecessary. (Furthermore, if the physician
knowingly reported this 40 percent blockage as 80 percent, stented it, and
billed for it, then it would constitute fraud). If the coronary artery blockage
was truly 80 percent then according to the results of the COURAGE trial, first
trying medical therapy alone could be as effective as immediately using stents
for the purposes of minimizing the cardiovascular mortality in this patient
(but perhaps not from the point of view of immediately relieving his symptoms).<span style="mso-spacerun: yes;"> </span>In this situation, the immediate stent
placement could also be considered “unnecessary.”<o:p></o:p></span></span></div>
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;"></span></span><br />
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;">With a proposal to add “</span><a href="http://www.annals.org/content/155/6/386.abstract"><span style="color: blue; font-family: Calibri;">cost-conscious care and
stewardship of resources</span></a><span style="font-family: Calibri;">” as one of the ACGME’s core competencies for
medical trainees, and with Medicare aggressively tightening its belt in order
to remain fiscally solvent, determining “<b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><u>unnecessary care</u></i></b>” will depend
on developing a consensus on the value of life, suffering, and the validity of
extrapolating scientific data analysis to a multitude of individual specific
patient situations.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>As health professionals and policy makers
appropriately engage in this discussion about what represents effective care
that health insurance should pay for, they should be careful not to equate outliers,
such as doctors facing criminal charges for fraud, with accepted variation in
standard practice that might encompasses care that some deem “unneeded.”<span style="mso-spacerun: yes;"> </span>Equating unneeded care with dishonest intent is
bound to elicit a highly emotional response from most doctors, who
are deeply committed to their professional obligation to do what they believe
is best for their patients.<o:p></o:p></span></span><br />
<br />
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt;">
<br /></div>
<br />
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt;">
<br /></div>
<br />
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt;">
<br /></div>
<br />
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;"><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><o:p></o:p></span></span></div>
</div><div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com2tag:blogger.com,1999:blog-3946741689271235070.post-43739568836477372082011-12-17T06:16:00.000-08:002011-12-17T06:16:04.000-08:00Are you at risk for an adverse medication reaction?<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEigUQ4bp9ANOXxz5S-FO6t5saC73TeujTSRU1zO8eWNKxrV3C0JoildL4D3BQ0Y1f0A87e1dkduaXkpOYdhm0fpBZm1oLCaBDVtvQZ7qTyadCg3fn5DHqfzkYsAbM7yzFGbOLq7lKg1IVJ6/s1600/multiple+pills.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="214" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEigUQ4bp9ANOXxz5S-FO6t5saC73TeujTSRU1zO8eWNKxrV3C0JoildL4D3BQ0Y1f0A87e1dkduaXkpOYdhm0fpBZm1oLCaBDVtvQZ7qTyadCg3fn5DHqfzkYsAbM7yzFGbOLq7lKg1IVJ6/s320/multiple+pills.png" width="320" /></a><span style="font-family: Calibri;">Many patients express concern about
being on long term medications. In my view, their concerns are
well-founded.<span style="mso-spacerun: yes;"> </span>At times the treatment can
be worse than the disease.<span style="mso-spacerun: yes;"> </span>According to </span><a href="http://www.cdc.gov/medicationsafety/basics.html"><span style="color: blue; font-family: Calibri;">CDC statistics</span></a><span style="font-family: Calibri;"> 82
percent of adults are on one or more medications, and 29 percent are on five or
more.<span style="mso-spacerun: yes;"> </span>Polypharmacy (the use of many
drugs together, or excessive medications) is a significant problem of the
elderly, and of those with chronic illness.<span style="mso-spacerun: yes;">
</span>These populations are at increased risk for drug-related adverse
reactions.<span style="mso-spacerun: yes;"> </span>How can a patient assure the
safety of his or her medication? Many turn to alternative medicine, under the
false impression that these substances are somehow safer than those that are
brought to market by the pharmaceutical industry.<span style="mso-spacerun: yes;"> </span>Others rely on medical professionals—doctors,
nurses, and pharmacists-- to warn them about the possibility of drug
interactions and toxicity. Electronic prescribing has improved drug safety by
automating cross-checking and alerting prescribers when two drugs
interact.<span style="mso-spacerun: yes;"> </span>However, in my experience
electronic systems can establish such low filters for reporting drug
interactions that virtually every drug prescribed may cause an alert to pop up.
Which of these interactions is clinically relevant? Often clinicians must use
their best guess as to whether two or more drugs in combination will be safe
for a particular patient. </span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt 0.5in;">
<span style="font-family: Calibri;">The cytochrome P450 enzymatic
system is involved in the metabolism of many drugs. Although there are more
than 50 of these enzymes, </span><a href="http://www.aafp.org/afp/2007/0801/p391.html"><span style="color: blue; font-family: Calibri;">only
six of them are responsible for the metabolism of 90 percent of drugs</span></a><span style="font-family: Calibri;">. Many
significant adverse drug events result from issues that involve this pathway.
Ingested substances, whether it’s grapefruit juice, a cup of coffee, an herbal
product, or a prescribed medication, can alter metabolism by inducing or
inhibiting the activity of the P450 enzymes. Moreover, research has revealed
that there is significant genetic variation in their activity from one
individual to the next.<span style="mso-spacerun: yes;"> </span>I’ve had many a
patient tell me of his or her unique sensitivity to drugs.<span style="mso-spacerun: yes;"> </span>These circumstantial observations may well be
founded in science, and </span><a href="http://www.blogger.com/.%20http:/www.nejm.org/doi/full/10.1056/NEJMra1010600"><span style="color: blue; font-family: Calibri;">pharmacogenetics</span></a><span style="font-family: Calibri;">
is an emerging field that describes the genetic variation in responses to
medication while one patient may have particularly efficacious P450 enzymes,
another may have P450s that are slower to operate. Two or more drugs that are
metabolized by the same P450 may compete and one drug may reduce the metabolism
of another, causing high levels of the “substrate” drug to accumulate, and
potentially cause toxicity.<span style="mso-spacerun: yes;"> </span>Other drugs
may up-regulate the digestive enzyme and cause a drug to be cleared more
rapidly than normal, reducing its concentration and therapeutic efficacy.</span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt 0.5in;">
<span style="font-family: Calibri;">Take the popular cholesterol
lowering medication simvastatin (Zocor).<span style="mso-spacerun: yes;">
</span>Simvastatin is used to lower cholesterol and has been associated with
important clinical outcomes in patients who are treated with it-- including a
reduction in cardiovascular death. However, its use has also been linked with
an adverse drug reaction--myopathy, or muscle damage.<span style="mso-spacerun: yes;"> </span>At its extreme myopathy is known as
“rhabdomyolysis,” a process that can lead to kidney failure and even
death.<span style="mso-spacerun: yes;"> </span>Rhabdomyolysis occurs at a rate
of 4.4 cases per 100,000 patients exposed to a “statin”-type medication (also
including atorvastatin, rosuvastatin, pravastatin). The risk of myopathy is
dose related and recently the </span><a href="http://www.fda.gov/Drugs/DrugSafety/ucm256581.htm%20http:/www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm258338.htm"><span style="color: blue; font-family: Calibri;">FDA
has warned against using the 80 mg dose of simvastatin</span></a><span style="font-family: Calibri;"> for treatment of
elevated cholesterol.<span style="mso-spacerun: yes;"> </span></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt 0.5in;">
<span style="font-family: Calibri;">Simavastatin’s metabolism occurs in
the liver with the P450 enzyme CYP3A4.<span style="mso-spacerun: yes;">
</span>Numerous other medications affect the activity of this enzyme.<span style="mso-spacerun: yes;"> </span>The calcium channel blocker amlodipine
(Norvasc) is processed by the same enzyme. Patients who take amlodipine and
simvastatin simultaneously may have reduced clearance of simvastatin, and may
be more prone to muscle damage from the drug.<span style="mso-spacerun: yes;">
</span>Consequently the FDA advises </span><a href="http://www.fda.gov/Drugs/DrugSafety/ucm256581.htm"><span style="color: blue; font-family: Calibri;">limiting simvastatin
dosing in this population to the 20 mg dose</span></a><span style="font-family: Calibri;">. However, enzymatic activity of
CYP3A4 is genetically determined.<span style="mso-spacerun: yes;"> </span>Within
the population certain individuals may be rapid or poor metabolizers of the
drug, impacting the generalizability of the FDA recommendations from one person
to the next. </span></div>
<br />
<div style="margin-left: 0.5in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;">Genetic testing for cytochrome P450
enzyme polymorphisms is not yet recommended. Yet, we are moving in that
direction, and no doubt the genetic polymorphisms may prove to provide valuable
insight into why particular patients may not respond to standard
treatments.<span style="mso-spacerun: yes;"> </span>For example the drug Plavix
(clopidogrel) is an important blood thinner that effects platelet activity and
is indicated in patients who have had a stroke, or who have had stents placed
for coronary artery disease.<span style="mso-spacerun: yes;"> </span>Clopidogrel
is a pro-drug-- it must be converted in the liver to its active form and
CYP2C19 is the predominate enzyme responsible for this conversion. </span></span><a href="http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm203888.htm"><span style="mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;"><span style="color: blue; font-family: Calibri;">Patients who are poor metabolizers of Plavix do not effectively
convert the drug to its active form</span></span></a><span style="mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;">. In these
patients, the drug is less effective at preventing heart attacks, strokes, and
cardiovascular death.<span style="mso-spacerun: yes;"> </span>It is estimated
that 2 to 14% of the population are poor metabolizers of Plavix; the rate
varies based on racial background.<span style="mso-spacerun: yes;"> </span>With
this finding, some have advocated genetic testing of all patients who need
Plavix for its important indication.<o:p></o:p></span></span></div>
<br />
<div style="margin-left: 0.5in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;">Another P450 issue has emerged with
Clopidogrel.<span style="mso-spacerun: yes;"> </span>The popular, and now over
the counter, proton pump inhibitor (PPI) omeprazole is metabolized by the same
hepatic enzyme and is an inhibitor of the enzyme, </span></span><a href="http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm190836.htm"><span style="mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;"><span style="color: blue; font-family: Calibri;">blocking the conversion of clopidogrel to its active form</span></span></a><span style="mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;"><span style="font-family: Calibri;">.<span style="mso-spacerun: yes;"> </span>However, not all PPIs
have the same degree of inhibitory effect on the enzyme (CYP 2C19). The drug
pantoprozole (Protonix) may be a less strong inhibitors, and therefore safer
for concomitant use with Plavix.<o:p></o:p></span></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt 0.5in; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman";"><span style="font-family: Calibri;">These two
examples demonstrate the complex determinants of drug metabolism—genetic and
environmental—and highlight the importance of using individualized treatment
plans </span></span><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">in order to optimize therapy and reduce the risk of
medication related toxicity.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-indent: 0.5in;">
<span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">*<em>The FDA website offers a drug </em></span><a href="http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm111085.htm"><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";"><span style="color: blue;"><em>Index
of Postmarket Safety Information for Patients and Providers</em></span></span></a><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";"><em>.
I found the website useful for specific drug information.<o:p></o:p></em></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt 0.5in;">
<br /></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt 0.5in;">
<br /></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<br /></div>
</div><div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com3tag:blogger.com,1999:blog-3946741689271235070.post-81255791899578302862011-11-09T13:46:00.000-08:002011-11-09T19:43:07.117-08:00Should Doctors Stop Using PSA to Screen for Prostate Cancer?<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSAh7_PQ7RmKrCxBl_2Ch7PEL-2oXr93xVrKwSXZHFpGuO4aUow4oQnyTdpIF1Y53uBCNzyx-NRISC2fDlunyahdiOotV-lBSydziNjsVIK9EgjPbOtSRxuAEz0MDfvKh6ogG1y1RThfRq/s1600/family-guy-rears-up-for-new-season-20060908114817345.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="198" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSAh7_PQ7RmKrCxBl_2Ch7PEL-2oXr93xVrKwSXZHFpGuO4aUow4oQnyTdpIF1Y53uBCNzyx-NRISC2fDlunyahdiOotV-lBSydziNjsVIK9EgjPbOtSRxuAEz0MDfvKh6ogG1y1RThfRq/s320/family-guy-rears-up-for-new-season-20060908114817345.jpg" width="320" /></a></div>
<span style="font-size: 12pt;"><span style="font-family: Calibri;">The United States Preventive Services
Task Force (USPSTF) says yes.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></span><br />
<span style="font-size: 12pt;"><span style="font-family: Calibri;"></span></span><br />
<span style="font-size: 12pt;"><span style="font-family: Calibri;">Recently the influential Task
Force gave the PSA (prostate specific antigen) screening test a “D” level rating, meaning that doctors should
recommend against using the test for the purpose of early detection.<span style="mso-spacerun: yes;"> </span>Prostate cancer is the second leading cause
of cancer death in men after lung cancer.<span style="mso-spacerun: yes;">
</span>Early detection of prostate cancer through screening with PSA was introduced into clinical practice in 1986.<span style="mso-spacerun: yes;"> </span>Over the past several decades prostate cancer
mortality has fallen by approximately 30%. Statistical modeling suggests that this might correlate
with the advent of screening with PSA.<span style="mso-spacerun: yes;"> </span>In
addition, over the past several decades there has been an increase in prostate
cancer incidence and a shift toward the detection of earlier stage
cancers—likely also a result of PSA screening.<o:p></o:p></span></span><br />
<br />
<span style="font-family: Calibri;"><span style="font-size: 12pt;">The purpose of health
screening is to detect disease in an earlier stage so that preventive measures
can be initiated to improve health outcomes related to that condition.<span style="mso-spacerun: yes;"> </span>However, in order to justify population level
screening, the benefit associated with early detection must outweigh the harm
that it potentially causes.<span style="mso-spacerun: yes;"> </span>Healthy
Americans and their physicians have embraced the practice of early detection,
particularly with respect to cancer, which along with Alzheimer’s disease, is
the most feared illness in our population.<span style="mso-spacerun: yes;">
</span>The USPSTF analyzed available data on prostate cancer screening and
treatment, including the results of the two largest clinical trials—one done in
the United States and the other in Europe.<span style="mso-spacerun: yes;">
</span>The American study (<a href="http://prevention.cancer.gov/plco">PLCO</a>) </span></span><span style="font-size: 12pt;"><span style="font-family: Calibri;"> found no mortality benefit with PSA screening after a
7 to 10 year period of follow up.<span style="mso-spacerun: yes;"> </span>Its
results have been criticized with the possibility that findings were
“contaminated” with too many men in the control group who received screening
before and during the study, reducing the apparent efficacy of PSA screening.<span style="mso-spacerun: yes;"> </span>In contrast, the European <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa0810084">ERSPC</a> study showed
a statistically significant, but small reduction in prostate cancer mortality
(20%), in men who were screened every 4 years over 9 years. </span></span><span style="font-size: 12pt;"><span style="font-family: Calibri;">Researchers found that 1,410 men would have to be
screened and 48 additional cancers would have to be detected to prevent one
death from prostate cancer.<span style="mso-spacerun: yes;"> </span>This
efficacy is similar in magnitude (slightly greater) to the effectiveness of
using mammography to screen women in their forties for breast cancer.<span style="mso-spacerun: yes;"> </span>A potential shortcoming of these studies is that
the study time could have been too short to detect benefit given that prostate
cancer may be very indolent.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt;"><span style="font-family: Calibri;">Needless to say urologists as
a professional group object to the USPSTF’s recommendation, stating on the
<a href="http://www.auanet.org/content/health-policy/government-relations-and-advocacy/in-the-news/uspstf-psa-recommendations.cfm?WT.mc_id=EML6621MKT">American Urologic Association</a> website:<span style="mso-spacerun: yes;"> </span></span></span></div>
<blockquote class="tr_bq">
<span style="font-size: 12pt;"><span style="font-family: Calibri;">The Task Force is doing men
a great disservice by disparaging what is now the only widely available test
for prostate cancer, a potentially devastating disease. We hold true to our
current position as supported by the AUA's </span></span><a href="http://www.auanet.org/content/media/psa09.pdf" target="_new"><i><span style="font-size: 12pt;"><span style="color: blue; font-family: Calibri;">Prostate-Specific Antigen Best Practice Statement</span></span></i></a><span style="font-size: 12pt;"><span style="font-family: Calibri;"> that, when interpreted appropriately, the PSA test
provides important information in the diagnosis, pre-treatment staging or risk
assessment and monitoring of prostate cancer patients. But not all prostate
cancers are life-threatening. The decision to proceed to active treatment or
use surveillance for a patient's prostate cancer is one that men should discuss
in detail with their urologists.</span></span></blockquote>
<span style="font-size: 12pt;"><span style="font-family: Calibri;">The argument against using
PSA to screen, itself an inexpensive blood test, is that it leads to
over-diagnosis of clinically insignificant prostate cancer.<span style="mso-spacerun: yes;"> </span>Postmortem data indicate that approximately
one third of men between the ages of 50 and 65 have microscopic evidence of
prostate cancer. This percentage increases to over 50 percent for men in their 70s and
80s. Analysis of data suggests that early detection leads to over-zealous
treatment—including radiation and radical prostatectomy.<span style="mso-spacerun: yes;"> </span>Over-treatment puts men in harm’s way with side
effects related to treatment --loss of continence (ability to control
urination) and erectile dysfunction.<span style="mso-spacerun: yes;"> </span>I
recently read a nice discussion the magnitude of risk associated with screening
by <a href="http://www.albertfuchs.com/blog/?p=814">Dr. Albert Fuchs</a>. </span><span style="font-family: Calibri;">
Both physicians and patients are participants in opting for aggressive
interventions for early stage cancer.<o:p></o:p></span></span><br />
<span style="font-size: 12pt;"><span style="font-family: Calibri;"></span></span><br />
<span style="font-size: 12pt;"><span style="font-family: Calibri;">Active surveillance or “watchful
waiting” is an acceptable strategy for managing elevated PSA or even biopsy
proven prostate cancer.<span style="mso-spacerun: yes;"> </span>In practical
terms this means that once cancer is detected it may be reasonable to do
nothing aside from monitoring for evidence of prostate cancer progression. In
some, this might entail monitoring the PSA velocity (or rate of increase) to
help determine an appropriate time to treat.<span style="mso-spacerun: yes;">
</span>Or, in others, it might include waiting to treat until the cancer
becomes symptomatic with urinary symptoms or symptoms related to prostate
cancer that has spread to the bone.<span style="mso-spacerun: yes;"> </span>However
it’s very difficult for patients and their doctors to sit tight with the
knowledge that they might be living with cancer.<span style="mso-spacerun: yes;"> </span>I’ve discussed the difficulty with watchful
waiting with respect to breast cancer in the blog: <a href="http://www.drdialogue.com/2010/03/is-watchful-waiting-too-difficult.html">“Is Watchful Waiting too Difficult?”</a><span style="mso-spacerun: yes;"> </span></span></span><br />
<br />
<span style="font-size: 12pt;"><span style="font-family: Calibri;">As for me, I tend to find the
USPSTF’s PSA screening recommendation a little too reactionary.<span style="mso-spacerun: yes;"> </span>As stated in a recent <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1111894?query=featured_home">New England Journal of Medicine editorial</a> </span><span style="font-family: Calibri;">a “C” level rating for this test might have been more appropriate.<span style="mso-spacerun: yes;"> </span>I am not completely ready to jump onto the
anti-PSA bandwagon that many of my fellow internists seem to be espousing and
go back to the 1970s.<span style="mso-spacerun: yes;"> </span>However, I do see
that a more cautionary approach to prostate cancer detection and treatment is
warranted.<span style="mso-spacerun: yes;"> </span>This will require discussion,
courage, and culture change on the part of primary care physicians, urologists,
and their patients alike as we try to effectively convey and accept the message
that early detection of cancer is good, but that not all early cancer, or “pre-cancer,”
needs early and aggressive intervention.</span></span><br />
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
</div><div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com0tag:blogger.com,1999:blog-3946741689271235070.post-35699894268329482272011-10-07T14:32:00.000-07:002011-10-12T17:16:29.213-07:00Screening for Inflammation with hsCRP<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgu8m4-zmhnhH8ul8-tkSzoAy5MSlukvUCo7_BS-rboVQ7LS3gdRTcqHn8VhM24OAfC7O3sW6z__uC32D1MQ5SoogyWkCm3h7UooKxwJ-bsXpAuu713BOv7HHp6i-b6vaB9hmjRe__rnbkR/s1600/inflammation.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="266" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgu8m4-zmhnhH8ul8-tkSzoAy5MSlukvUCo7_BS-rboVQ7LS3gdRTcqHn8VhM24OAfC7O3sW6z__uC32D1MQ5SoogyWkCm3h7UooKxwJ-bsXpAuu713BOv7HHp6i-b6vaB9hmjRe__rnbkR/s320/inflammation.jpg" width="320" /></a></div>
<span style="font-family: Calibri;">For several years now I’ve been screening many of my
patients for inflammation with their annual physical examination using blood
test known as high sensitivity c-reactive protein or hsCRP. <span style="mso-spacerun: yes;"> </span>HsCRP is an inflammatory marker that has
proven useful as a marker for cardiovascular risk in some individuals.<span style="mso-spacerun: yes;"> </span>Inflammation occurs when there is tissue
damage.<span style="mso-spacerun: yes;"> </span>In general, ongoing inflammation
is not good for one’s health.<span style="mso-spacerun: yes;"> </span>In the
case of arthritis, inflammation affects bones and joints. In the case of
infection, inflammation results when the immune system responds to a
pathogen.<span style="mso-spacerun: yes;"> </span>In the case of cancer,
inflammation occurs as cancerous cells invade healthy tissues and cause
damage.<span style="mso-spacerun: yes;"> </span>More recently, inflammation has
been identified as an important factor in atherosclerosis, the process that
leads to cholesterol plaque accumulation in blood vessels resulting in heart
attack, stroke, and peripheral vascular disease.<span style="mso-spacerun: yes;"> </span></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">CRP is an acute phase reactant, so its level may go up with infection
or trauma.<span style="mso-spacerun: yes;"> </span>However, in general, hsCRP
levels tend to be relatively stable over time, compared with other inflammatory
markers.<span style="mso-spacerun: yes;"> </span>Multiple studies have
demonstrated the relationship between hsCRP elevation and cardiovascular
disease.<span style="mso-spacerun: yes;"> </span>In fact, with respect to
cardiovascular risk, hsCRP is said to be more predictive of cardiovascular events
than LDL cholesterol levels.<span style="mso-spacerun: yes;"> </span>Three levels
of risk have been identified:</span></div>
<span style="font-family: Calibri;">Low risk <span style="mso-tab-count: 3;"> </span>hsCRP
< 1 mg/L</span><br />
<br />
<span style="font-family: Calibri;">Moderate risk <span style="mso-tab-count: 3;"> </span>hsCRP
1-3 mg/L</span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">High risk<span style="mso-tab-count: 3;"> </span>hsCRP<span style="mso-spacerun: yes;"> </span>>3 mg/L</span></div>
<span style="font-family: Calibri;">In the <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa0807646">Jupiter</a> trial healthy men and women with normal LDL
cholesterol (<130) but elevated hsCRP (>2 mg/L) were randomized to
receive 20 mg of Rosuvastatin or placebo. </span><span style="font-family: Calibri;">
The trial was halted early when the treatment group was found to have
significantly lower risk of cardiovascular events in the 1.9 years that the
subjects were studied.<span style="mso-spacerun: yes;"> </span>The reduction in
risk correlated with a reduction in LDL cholesterol and hsCRP levels.</span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">In my patient population it is my experience that about 25
percent of my patients have hsCRP levels that exceed the 3 mg/L threshold for “high
risk.” About 5 to 10% of my screened patients have levels that substantially
exceed 3mg/L.<span style="mso-spacerun: yes;"> </span>As a generalist, I have
been tasked to take action with these particular patients, bringing them back
in to the office for a thorough history to exclude occult infection, ordering
additional tests to screen for occult rheumatologic disorders, and to make sure
cancer prevention guidelines have been followed—and at times doing additional
work-ups.</span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Elevated CRP has also been associated with diabetes and
metabolic syndrome.<span style="mso-spacerun: yes;"> </span>One patient in her
50s had an hsCRP of 28. This patient also had new onset diabetes, with a
hemoglobin A1C of 8.1, LDL cholesterol of 136, and BMI of 42. After losing 70
pounds (over one year) and with resolution of her diabetes my patient’s hsCRP
came down to 3.<span style="mso-spacerun: yes;"> </span>A statin was started in
addition to aspirin therapy.<span style="mso-spacerun: yes;"> </span>In this
case the crp did not alter my practice, though it did raise my level of
concern.</span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Another healthy patient in her forties had a level of 3.5 mg/L.<span style="mso-spacerun: yes;"> </span>The patient, who is vegan, had an LDL of 80,
an HDL of 78, a normal glucose, does not smoke, and has a body mass index of
23.<span style="mso-spacerun: yes;"> </span>Framingham risk was calculated at less
than 1 percent. My patient had astutely read of an association of between elevated
CRP and Alzheimer’s Disease risk (which has been described). <span style="mso-spacerun: yes;"> </span>Unfortunately, there is no clear and proven intervention
to reduce this patient’s potential health risk, which is still likely low. I
placed her on aspirin 81 mg daily.</span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Within the realm of using hsCRP <span style="mso-spacerun: yes;"> </span>for the purpose of primary prevention medical knowledge
is based primarily on cardiovascular trials and outcomes.<span style="mso-spacerun: yes;"> </span>According to one expert author CRP may be at
least 50% genetically pre-determined.<span style="mso-spacerun: yes;"> </span>In
the case of my healthy patient in her 40’s this seems likely. I was reassured
to read a summary in <a href="http://circ.ahajournals.org/content/108/12/e81.full.pdf+html">Circulation</a> noting that while a relationship between high
crp and cardiovascular death has been demonstrated, elevated hsCRP has not been
linked to increased mortality from other causes (like cancer). At least this
finding will allow me to focus on cardiovascular health when hsCRP is high, as
opposed to engaging in a wild goose chase to detect occult illness. </span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">HsCRP measurement is currently recommended only in
individuals who are at intermediate risk for cardiovascular disease (defined as
10 to 20 percent chance of having a cardiovascular event in ten years). In this
population it can prompt more aggressive management of risk factors, including beginning
a statin for only marginally elevated cholesterol.<span style="mso-spacerun: yes;"> </span>One review in the <a href="http://www.annals.org/content/145/1/35.short">Annals of Internal Medicine</a>
noted that while high hsCRP levels in women with intermediate or high
<a href="http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof">Framingham risk</a> </span><span style="font-family: Calibri;">
correlated with worse cardiovascular outcomes, high levels in women deemed to
be at low risk by Framingham did not correlate with substantially high vascular
risk. </span><span style="font-family: Calibri;">
<span style="mso-spacerun: yes;"> </span>Despite this finding, at times I have still
found it helpful to check hsCRP within a low risk population. The test is
inexpensive, it can help as a motivator to prompt lifestyle change that could
prevent future increased risk, and 20 percent of heart disease may occur in
those with no traditional risk factors. <span style="mso-spacerun: yes;"> </span>As a novel risk factor hsCRP has become one of
many variables known to contribute to cardiovascular health.<span style="mso-spacerun: yes;"> </span>However, as an isolated finding it still may
have limited utility, raising questions that at this time still have no clear
cut answers.</span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<br /></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<br /></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<br /></div>
</div><div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com0tag:blogger.com,1999:blog-3946741689271235070.post-71483832960176500132011-09-19T14:31:00.000-07:002011-09-19T14:31:14.105-07:00Sifting Through the Mammogram Muck<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7zqOnQrqISzWpa4sRt4iwe7INv_69Bm-z7-Nb4RDyg1H0UrJzQyWMzJ_Wmed_4UdVrXVRVn0EClR8NluzJ0_zHIP1YA9PJwdEuWScmzpiMQzxcINDbNreYzxgL2ae3XMhkz3xoz2WM-ZQ/s1600/mammography.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7zqOnQrqISzWpa4sRt4iwe7INv_69Bm-z7-Nb4RDyg1H0UrJzQyWMzJ_Wmed_4UdVrXVRVn0EClR8NluzJ0_zHIP1YA9PJwdEuWScmzpiMQzxcINDbNreYzxgL2ae3XMhkz3xoz2WM-ZQ/s200/mammography.jpg" width="179" /></a></div>
<span style="font-family: Calibri;">In November of 2009 the United States Preventive Services
Task Force (USPSTF) revised its <a href="http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm">guideline on the use of mammography</a> </span><span style="font-family: Calibri;">
to screen for breast cancer, recommending against routine screening of women
ages 40 to 49, and changing the screening interval for women ages 50 to 74 from
annual screening to screening every two years.<span style="mso-spacerun: yes;"> </span>This recommendation left doctors and
patients alike confused over what to do.<span style="mso-spacerun: yes;">
</span>With a backlash of public opinion protesting the new recommendations, organizations
such as the <a href="http://www.cancer.org/Cancer/BreastCancer/MoreInformation/BreastCancerEarlyDetection/breast-cancer-early-detection-acs-recs">American Cancer Society</a> </span><span style="font-family: Calibri;">
continue to support routine annual screening of women beginning at age forty.</span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">What is a health-conscious woman to do?<span style="mso-spacerun: yes;"> </span>Randomized controlled trials (RCTs) have demonstrated
reductions in breast cancer mortality in women screened with mammography beginning at 40. Screening is most
effective in women ages 50 to 69.<span style="mso-spacerun: yes;"> </span>A <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2972726/">meta-analysis</a>
done in 2009 for the purpose of updating breast cancer screening guidelines
found very little benefit to screening
women in the youngest age bracket (40-49) with mammography given the lower
disease incidence and higher number needed to screen (1904) to prevent one
cancer death. </span></div>
<span style="font-family: Calibri;">In the United States, the lifetime risk of breast cancer in
a woman is approximately 12 percent, or 1 in 8. The risk of a woman developing
breast cancer between ages 40 and 49 is 1.45 percent, or 1 in 69, which is why
if you are in your forties, you likely know several women who have been
diagnosed. The risk between ages 60 and 69 is 3.45%, or 1 in 29. About 5 to 15% of mammograms are abnormal and require further follow up. <span style="mso-spacerun: yes;">
</span>The sensitivity of mammography for detecting breast cancer is about eighty five percent, with a false negative rate of about fifteen percent. However, because of the low
disease prevalence in younger women, the risk of an abnormal mammogram being a
true positive is less than ten percent. In fact, for a woman who has annual mammograms each
year during her forties, there is an about thirty percent chance of having an abnormal during that decade. Given
these statistics and the mixed study results, the USPSTF decided that the <a href="http://courses.washington.edu/hmed665o/Mammogram.pdf">potential harm</a> </span><span style="font-family: Calibri;">of routine mammography in women ages 40 to 49 outweighed the potential for
benefit for most women, with the exception of those at highest risk. </span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">However, recently the outcomes of a very large population based
study (the <a href="http://onlinelibrary.wiley.com/doi/10.1002/cncr.25650/abstract">SCRY</a> study) of mammography in women ages 40 to 49 conducted in Sweden were published.
In the study, women who had an average of 6 mammograms in 10 years had reduced
breast cancer mortality compared with those who were not screened. The observed
“number needed to screen” in order to prevent one breast cancer death was 1252
women.<span style="mso-spacerun: yes;"> </span></span></div>
<span style="font-family: Calibri;">What comprises high clinical risk of breast cancer? Family
history and prior history of breast biopsy are important.<span style="mso-spacerun: yes;"> </span>Increased breast tissue density is also known
to confer higher breast cancer risk.<a href="http://www.cancer.gov/bcrisktool/Default.aspx"> Clinical risk calculators</a> may be used to quantify
risk.<span style="mso-spacerun: yes;"> </span></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">What about alternate screening modalities—ultrasound or MRI?<span style="mso-spacerun: yes;"> </span>Ultrasound is useful for
differentiating a fluid filled cyst from a solid breast mass—however, it has
limited utility for distinguishing between benign and malignant solid nodules
and also cannot detect in situ breast cancer (DCIS), which typically presents
as characteristic breast calcification on mammography.<span style="mso-spacerun: yes;"> </span>Breast MRI is a sensitive screening modality and
is recommended for women with genetic breast cancer risk—BRCA1 and BRCA2,
or with a calculated lifetime breast cancer risk of over 15 to 20%.<span style="mso-spacerun: yes;"> </span>Those with prior DCIS, lobular carcinoma in
situ, atypical ductal or lobular hyperplasia, or extremely dense breast tissue
may also benefit.<span style="mso-spacerun: yes;"> </span></span></div>
<span style="font-family: Calibri;">Given the recent recommendations
and findings a dogmatic approach to breast cancer screening should no longer be
the norm-- the approach should be personalized. Women should be asked about
their individual history, clinical risk factors, family history and personal
screening preferences during each annual visit.<span style="mso-spacerun: yes;">
</span>A clinical breast examination should be performed. <span style="mso-spacerun: yes;"> </span>If both history and examination point to low or average risk, I support screening every two years after baseline
mammography is performed at age 40.<span style="mso-spacerun: yes;"> </span>With
additional risk factors, including dense breast tissue, family history,
previous biopsy or abnormal clinical exam, I support annual mammography
beginning at age 40.<span style="mso-spacerun: yes;"> </span>At the other end of
the spectrum, at this time I also support continuing to perform screening mammography
in healthy and functional women who are over age 75 and whose life expectancy
is greater than 10 years.<span style="mso-spacerun: yes;"> </span></span><br />
</div>
<div class="blogger-post-footer"><script type="text/javascript">
var _gaq = _gaq || [];
_gaq.push(['_setAccount', 'UA-16991005-1']);
_gaq.push(['_trackPageview']);
(function() {
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
})();
</script></div>Juliet Mavromatis, MDhttp://www.blogger.com/profile/15621812541697154967noreply@blogger.com1