The specificity of D-dimer testing in patients with suspected pulmonary embolism and impaired renal function is significantly decreased. Nonetheless, performing D-dimer tests is still useful because computed tomography scanning can be withheld in a significant proportion of these patients.
Abstract
Background
Determination of pretest probability and D-dimer tests are the first diagnostic steps in patients with suspected pulmonary embolism, which can be ruled out when clinical probability is unlikely and D-dimerlevel is normal. We evaluated the utility of D-dimer testing in patients with impaired renal function.
Methods
D-dimer tests were performed in consecutive patients with suspected pulmonary embolism and an unlikely clinical probability. Creatinine levels were assessed as clinical routine. Glomerular filtration rate was calculated using the Modification of Diet in Renal Disease formula. Correlation between D-dimer level and renal function and proportions of patients with normal D-dimer in different categories of estimated glomerular filtration rate (eGFR) were assessed. Different categories of decreasing eGFR were defined as: normal renal function (eGFR >89 mL/min), mild decrease in eGFR (eGFR 60-89 mL/min), and moderate decrease in eGFR (eGFR 30-59 mL/min).
Results
Creatinine levels were assessed in 351 of 385 patients (91%). D-dimer levels significantly increased in 3 categories of decreasing eGFR (P = .027 and P = .021 for moderate renal impairment compared with mild renal impairment and normal renal function, respectively). Normal D-dimer levels were found in 58% of patients with eGFR >89 mL/min, in 54% with eGFR 60-89 mL/min, and in 28% with eGFR 30-59 mL/min.
Conclusions
The specificity of D-dimer testing in patients with suspected pulmonary embolism and decreased GFR is significantly decreased. Nonetheless, performing D-dimer tests is still useful because computed tomography scanning can be withheld in a significant proportion of these patients.
To read this article in its entirety, please visit our website.
-- Reza Karami-Djurabi, MD, Frederikus A. Klok, MD, Judith Kooiman, Sophie I. Velthuis, Mathilde Nijkeuter, MD, PhD, Menno V. Huisman, MD, PhD
This article was originally published in the November 2009 issue of The American Journal of Medicine.
Kamis, 10 Desember 2009
The Obesity Paradox, Weight Loss, and Coronary Disease
Although an obesity paradox exists, in that coronary heart disease patients with higher body mass index or higher percent body fat have lower mortality than those with less obesity, the results of this study support the safety and potential long-term benefits of purposeful weight loss in overweight and obese patients with coronary heart disease.
Abstract
Purpose
Because obesity is a cardiovascular risk factor but is associated with a more favorable prognosis among cohorts of cardiac patients, we assessed this “obesity paradox” in overweight and obese patients with coronary heart disease enrolled in a cardiac rehabilitation and exercise training (CRET) program, making this assessment in patients classified as overweight/obese using both traditional body mass index (BMI) and percent body fat assessments. Additionally, we assessed the efficacy and safety of purposeful weight loss in overweight and obese coronary patients.
Patients and Methods
We retrospectively studied 529 consecutive CRET patients following major coronary events before and after CRET, and compared baseline and post program data in 393 overweight and obese patients (body mass index [BMI] ≥25 kg/m2) divided by median weight change (median = −1.5%; mean +2% vs −5%, respectively). In addition, we assessed 3-year total mortality in various baseline BMI categories as well as compared mortality in those with high baseline percent fat (>25% in men and >35% in women) versus those with low baseline fat.
Results
Following CRET, the overweight and obese with greater weight loss had improvements in BMI (−5%; P<.0001), percent fat (−8%; P <.0001), peak oxygen consumption (+16%; P <.0001), low-density lipoprotein cholesterol (−5%; P <.02), high-density lipoprotein cholesterol (+10%; P <.0001), triglycerides (−17%; P<.0001), C-reactive protein (−40%; P <.0001), and fasting glucose (−4%; P = .02), as well as marked improvements in behavioral factors and quality-of-life scores. Those with lower weight loss had no significant improvements in percent fat, low-density lipoprotein cholesterol, triglycerides, C-reactive protein, and fasting glucose. During 3-year follow-up, overall mortality trended only slightly lower in those with baseline overweightness/obesity who had more weight loss (3.1% vs 5.1%; P = .30). However, total mortality was considerably lower in the baseline overweight/obese (BMI ≥25 kg/m2) than in 136 CRET patients with baseline BMI <25 kg/m2 (4.1% vs 13.2%; P <.001), as well as in those with high baseline fat compared with those with low fat (3.8% vs 10.6%; P <.01).
Conclusions
Purposeful weight loss with CRET in overweight/obese coronary patients is associated with only a nonsignificant trend for lower mortality but is characterized by marked improvements in obesity indices, exercise capacity, plasma lipids, and inflammation, as well as behavioral factors and quality of life. Although an “obesity paradox” exists using either baseline BMI or baseline percent fat criteria, these results support the safety and potential long-term benefits of purposeful weight loss in overweight and obese patients with coronary heart disease.
To read this article in its entirety, please visit our website.
-- Carl J. Lavie, MD, Richard V. Milani, MD, Surya M. Artham, MD, MPH, Dharmendrakumar A. Patel, MD, MPH, Hector O. Ventura, MD
This article was originally published in the December 2009 issue of The American Journal of Medicine.
Abstract
Purpose
Because obesity is a cardiovascular risk factor but is associated with a more favorable prognosis among cohorts of cardiac patients, we assessed this “obesity paradox” in overweight and obese patients with coronary heart disease enrolled in a cardiac rehabilitation and exercise training (CRET) program, making this assessment in patients classified as overweight/obese using both traditional body mass index (BMI) and percent body fat assessments. Additionally, we assessed the efficacy and safety of purposeful weight loss in overweight and obese coronary patients.
Patients and Methods
We retrospectively studied 529 consecutive CRET patients following major coronary events before and after CRET, and compared baseline and post program data in 393 overweight and obese patients (body mass index [BMI] ≥25 kg/m2) divided by median weight change (median = −1.5%; mean +2% vs −5%, respectively). In addition, we assessed 3-year total mortality in various baseline BMI categories as well as compared mortality in those with high baseline percent fat (>25% in men and >35% in women) versus those with low baseline fat.
Results
Following CRET, the overweight and obese with greater weight loss had improvements in BMI (−5%; P<.0001), percent fat (−8%; P <.0001), peak oxygen consumption (+16%; P <.0001), low-density lipoprotein cholesterol (−5%; P <.02), high-density lipoprotein cholesterol (+10%; P <.0001), triglycerides (−17%; P<.0001), C-reactive protein (−40%; P <.0001), and fasting glucose (−4%; P = .02), as well as marked improvements in behavioral factors and quality-of-life scores. Those with lower weight loss had no significant improvements in percent fat, low-density lipoprotein cholesterol, triglycerides, C-reactive protein, and fasting glucose. During 3-year follow-up, overall mortality trended only slightly lower in those with baseline overweightness/obesity who had more weight loss (3.1% vs 5.1%; P = .30). However, total mortality was considerably lower in the baseline overweight/obese (BMI ≥25 kg/m2) than in 136 CRET patients with baseline BMI <25 kg/m2 (4.1% vs 13.2%; P <.001), as well as in those with high baseline fat compared with those with low fat (3.8% vs 10.6%; P <.01).
Conclusions
Purposeful weight loss with CRET in overweight/obese coronary patients is associated with only a nonsignificant trend for lower mortality but is characterized by marked improvements in obesity indices, exercise capacity, plasma lipids, and inflammation, as well as behavioral factors and quality of life. Although an “obesity paradox” exists using either baseline BMI or baseline percent fat criteria, these results support the safety and potential long-term benefits of purposeful weight loss in overweight and obese patients with coronary heart disease.
To read this article in its entirety, please visit our website.
-- Carl J. Lavie, MD, Richard V. Milani, MD, Surya M. Artham, MD, MPH, Dharmendrakumar A. Patel, MD, MPH, Hector O. Ventura, MD
This article was originally published in the December 2009 issue of The American Journal of Medicine.
Nailing the Diagnosis!
Physical examination plays a crucial role in patient evaluation by confirming the hypotheses during history taking, suggesting new clues, and directing investigations. We describe how the recognition of a nail abnormality led us to the recognition of the cause of long-standing lymphedema and pleural effusion.
To read this article in its entirety, please visit our website.
-- Srinivas Rajagopala, MD, Navneet Singh, MD, DM, Dheeraj Gupta, MD, DM, FCCP
This article was originally published in the December 2009 issue of The American Journal of Medicine.
To read this article in its entirety, please visit our website.
-- Srinivas Rajagopala, MD, Navneet Singh, MD, DM, Dheeraj Gupta, MD, DM, FCCP
This article was originally published in the December 2009 issue of The American Journal of Medicine.
Commentary: The Bottom Line
Consideration of the forgoing will lead you to realize that the practice of medicine is predominantly a humanistic act. Physicians must care about their patients, and they must constantly improve their scientific knowledge about disease. To care and not know is dangerous. To know and not care is even worse. Caring and knowing must be combined to succeed in doctoring.
-- J. Willis Hurst, MD1
The thin thread that holds our existence in this life is broken every time we become sick. We seek medical care to restore our homeostasis through remedies and drugs provided by medical healers. Nonetheless, there is an untold and intense connection between the patient and the clinician that has been traditionally upheld as the key element of the therapeutic patient–physician relationship. In fact, more than the remedies, as patients, we expect to be listened to and cared for by compassionate and competent physicians. A listening and caring physician may turn out to be a more effective healer than the most scientifically updated physician who has little empathy. However, the major threat to this sacred connection between the provider and the patient is the growing practice of the business of medicine where care is sacrificed to see a greater number of “clients,” and thus increased billing.
The practice of clinical medicine is rapidly transforming with the current worldwide economic crisis. Although no one denies the importance of running a practice in a fiscally responsible way, the core ideals behind “physicianhood” and its mission also seem to be faltering.
To read this article in its entirety, please visit our website.
-- Carlos Franco-Paredes, MD, MPH, Phyllis Kozarsky, MD
This article was originally published in the December 2009 issue of The American Journal of Medicine.
-- J. Willis Hurst, MD1
The thin thread that holds our existence in this life is broken every time we become sick. We seek medical care to restore our homeostasis through remedies and drugs provided by medical healers. Nonetheless, there is an untold and intense connection between the patient and the clinician that has been traditionally upheld as the key element of the therapeutic patient–physician relationship. In fact, more than the remedies, as patients, we expect to be listened to and cared for by compassionate and competent physicians. A listening and caring physician may turn out to be a more effective healer than the most scientifically updated physician who has little empathy. However, the major threat to this sacred connection between the provider and the patient is the growing practice of the business of medicine where care is sacrificed to see a greater number of “clients,” and thus increased billing.
The practice of clinical medicine is rapidly transforming with the current worldwide economic crisis. Although no one denies the importance of running a practice in a fiscally responsible way, the core ideals behind “physicianhood” and its mission also seem to be faltering.
To read this article in its entirety, please visit our website.
-- Carlos Franco-Paredes, MD, MPH, Phyllis Kozarsky, MD
This article was originally published in the December 2009 issue of The American Journal of Medicine.
Selasa, 01 Desember 2009
An Aberrant Internal Carotid Artery in the Mouth
The cervical internal carotid artery normally runs straight to the skull base without branching.(1) However, aberrant courses of the extracranial internal carotid artery are not rare and may place the vessel in close relationship with the pharyngeal wall.(2, 3) We present this clinical observation to draw the readers' attention on a probably underappreciated anatomic variation.
A 77-year-old woman had long-standing moderate dysphagia and right-sided foreign body sensations in the throat. She had no history of alcohol or tobacco abuse. On examination, smooth irritation-free mucous membranes were found, but a funicular pulsatile mass was detected on the posterior pharyngeal wall on the right. Endoscopy displayed that the mass continued down to the hypopharynx. It was finally attributed to an aberrant course of the internal carotid artery. The patient was instructed to advise every treating physician of this anatomic variation and to abstain from sharp-edged food such as chicken bones and fish.
Pronounced extracranial aberrations of the internal carotid artery have a calculated incidence of 5% in the general population and can often be found bilaterally. They result from embryologic maldevelopment and age-related loss of elasticity in the vessel wall. These anatomic variations remain asymptomatic in the majority of cases but can also become apparent with dysphagia, pharyngeal foreign body sensations, intraoral pulsations, or signs of cerebrovascular insufficiency in case of sharp vessel bends.1, 2, 3 If placed in close opposition with the pharyngeal wall (Figure 1A and B), an aberrant internal carotid artery is at risk of injury during intubation, endoscopy, and routine pharyngeal or dental procedures. It may also be misdiagnosed as a parapharyngeal tumor.2, 3 Therefore, the awareness of extracranial aberrations of the internal carotid artery is essential for every clinician.
References
1. Paulsen F, Tillmann B, Christofides C, et al. Curving and looping of the internal carotid artery in relation to the pharynx: frequency, embryology and clinical implications. J Anat. 2000;197:373–381.
2. Hertzanu Y, Tovi F. Radiology case of the month (Aberrant internal carotid artery manifesting as a pharyngeal mass). J Otolaryngol. 1992;21:294–296.MEDLINE
3. Ricciardelli E, Hillel AD, Schwartz AN. Aberrant carotid artery (Presentation in the near midline pharynx). Arch Otolaryngol Head Neck Surg.1989;115:519–522. MEDLINE
-- Jens Pfeiffer, MD, Gerd J. Ridder, MD
This article was originally published in the March 2009 issue of The American Journal of Medicine.
A 77-year-old woman had long-standing moderate dysphagia and right-sided foreign body sensations in the throat. She had no history of alcohol or tobacco abuse. On examination, smooth irritation-free mucous membranes were found, but a funicular pulsatile mass was detected on the posterior pharyngeal wall on the right. Endoscopy displayed that the mass continued down to the hypopharynx. It was finally attributed to an aberrant course of the internal carotid artery. The patient was instructed to advise every treating physician of this anatomic variation and to abstain from sharp-edged food such as chicken bones and fish.
Pronounced extracranial aberrations of the internal carotid artery have a calculated incidence of 5% in the general population and can often be found bilaterally. They result from embryologic maldevelopment and age-related loss of elasticity in the vessel wall. These anatomic variations remain asymptomatic in the majority of cases but can also become apparent with dysphagia, pharyngeal foreign body sensations, intraoral pulsations, or signs of cerebrovascular insufficiency in case of sharp vessel bends.1, 2, 3 If placed in close opposition with the pharyngeal wall (Figure 1A and B), an aberrant internal carotid artery is at risk of injury during intubation, endoscopy, and routine pharyngeal or dental procedures. It may also be misdiagnosed as a parapharyngeal tumor.2, 3 Therefore, the awareness of extracranial aberrations of the internal carotid artery is essential for every clinician.
References
1. Paulsen F, Tillmann B, Christofides C, et al. Curving and looping of the internal carotid artery in relation to the pharynx: frequency, embryology and clinical implications. J Anat. 2000;197:373–381.
2. Hertzanu Y, Tovi F. Radiology case of the month (Aberrant internal carotid artery manifesting as a pharyngeal mass). J Otolaryngol. 1992;21:294–296.MEDLINE
3. Ricciardelli E, Hillel AD, Schwartz AN. Aberrant carotid artery (Presentation in the near midline pharynx). Arch Otolaryngol Head Neck Surg.1989;115:519–522. MEDLINE
-- Jens Pfeiffer, MD, Gerd J. Ridder, MD
This article was originally published in the March 2009 issue of The American Journal of Medicine.
Senin, 30 November 2009
Back to the Future: Medical Students Can Matter Again
Over the last 5 years, we have spent considerable time directly teaching students and housestaff and have been involved in numerous meetings of academic physicians concerned about the apparent erosion in quantity and quality of medical student and resident teaching at our medical schools and teaching hospitals.
The causes of this progressive deterioration in what many consider the best medical education system in the world are myriad: Economic challenges forced faculty to spend much of their time doing direct clinical work rather than teaching; program directors have needed to spend more time and effort on regulatory documentation; administrative restrictions have been placed on medical student participation in patient care; duty hour constraints have been placed on resident work schedules, thereby decreasing the amount of time that residents can devote to teaching students as well as each other; and inpatient physicians are given performance metrics that emphasize efficiency of patient flow at the expense of bedside teaching and role modeling. Departments of medicine have evolved into business centers or “product lines” instead of the medical center's academic compass.
Teachers have less time to teach; residents have less time to learn; and medical students are often relegated to the role of voyeurs. And from this environment we hope to find the solution to reverse the trend of dwindling number of students seeking careers as general internists and academicians.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD, Brian F. Mandell, MD, PhD
This article was originally published in the November 2009 issue of The American Journal of Medicine.
The causes of this progressive deterioration in what many consider the best medical education system in the world are myriad: Economic challenges forced faculty to spend much of their time doing direct clinical work rather than teaching; program directors have needed to spend more time and effort on regulatory documentation; administrative restrictions have been placed on medical student participation in patient care; duty hour constraints have been placed on resident work schedules, thereby decreasing the amount of time that residents can devote to teaching students as well as each other; and inpatient physicians are given performance metrics that emphasize efficiency of patient flow at the expense of bedside teaching and role modeling. Departments of medicine have evolved into business centers or “product lines” instead of the medical center's academic compass.
Teachers have less time to teach; residents have less time to learn; and medical students are often relegated to the role of voyeurs. And from this environment we hope to find the solution to reverse the trend of dwindling number of students seeking careers as general internists and academicians.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD, Brian F. Mandell, MD, PhD
This article was originally published in the November 2009 issue of The American Journal of Medicine.
Should We Maintain an Open Mind about Homeopathy?
Once upon a time, doctors had little patience with the claims made for alternative medicines. In recent years the climate has changed dramatically. It is now politically correct to have an open mind about such matters; “the patient knows best” and “it worked for me” seem to be the new mantras. Although this may be a reasonable approach to some of the more plausible aspects of alternative medicine, such as herbal medicine or physical therapies that require manipulation, we believe it cannot apply across the board. Some of these alternatives are based on obsolete or metaphysical concepts of human biology and physiology that have to be described as absurd with proponents who will not subject their interventions to scientific scrutiny or if they do, and are found wanting, suggest that the mere fact of critical evaluation is sufficient to chase the healing process away. These individuals have a conflict of interest more powerful than the requirement for scientific integrity and yet defend themselves by claiming that those wanting to carry out the trials are in the pocket of the pharmaceutical industry and are part of a conspiracy to deny their patients tried and tested palliatives.
To read this article in its entirety, please visit our website.
-- Michael Baum, MD, ChM, Edzard Ernst, MD, PhD
This article was originally published in the November 2009 issue of The American Journal of Medicine.
To read this article in its entirety, please visit our website.
-- Michael Baum, MD, ChM, Edzard Ernst, MD, PhD
This article was originally published in the November 2009 issue of The American Journal of Medicine.
Bayesian Meta-analysis of Hormone Therapy and Mortality in Younger Postmenopausal Women
This careful meta-analysis indicates that hormone therapy reduces total mortality by 25% in younger postmenopausal women. A similar reduction in mortality has been seen in randomized trials and observational studies.
Abstract
Background
There is uncertainty over the risks and benefits of hormone therapy. We performed a Bayesian meta-analysis to evaluate the effect of hormone therapy on total mortality in younger postmenopausal women. This analysis synthesizes evidence from different sources, taking into account varying views on the issue.
Methods
A comprehensive search from 1966 through January 2008 identified randomized controlled trials of at least 6 month's duration that evaluated hormone therapy in women with mean age <60 years and reported at least one death, and prospective observational cohort studies that evaluated the relative risk of mortality associated with hormone therapy after adjustment for confounding variables.
Results
The results were synthesized using a hierarchical random-effects Bayesian meta-analysis. The pooled results from 19 randomized trials, with 16,000 women (mean age 55 years) followed for 83,000 patient-years, showed a mortality relative risk of 0.73 (95% credible interval 0.52-0.96). When data from 8 observational studies were added to the analysis, the resultant relative risk was 0.72 (credible interval 0.62-0.82). The posterior probability that hormone therapy reduces total mortality in younger women is almost 1.
Conclusions
The synthesis of data using Bayesian meta-analysis indicates a reduction in mortality in younger postmenopausal women taking hormone therapy compared with no treatment. This finding should be interpreted taking into account the potential benefits and harms of hormone therapy.
To read this article in its entirety, please visit our website.
-- Shelley R. Salpeter, MD, Ji Cheng, MSc, Lehana Thabane, PhD, Nicholas S. Buckley, Edwin E. Salpeter, PhD (Posthumous)
This article was originally published in the November 2009 issue of The American Journal of Medicine.
Abstract
Background
There is uncertainty over the risks and benefits of hormone therapy. We performed a Bayesian meta-analysis to evaluate the effect of hormone therapy on total mortality in younger postmenopausal women. This analysis synthesizes evidence from different sources, taking into account varying views on the issue.
Methods
A comprehensive search from 1966 through January 2008 identified randomized controlled trials of at least 6 month's duration that evaluated hormone therapy in women with mean age <60 years and reported at least one death, and prospective observational cohort studies that evaluated the relative risk of mortality associated with hormone therapy after adjustment for confounding variables.
Results
The results were synthesized using a hierarchical random-effects Bayesian meta-analysis. The pooled results from 19 randomized trials, with 16,000 women (mean age 55 years) followed for 83,000 patient-years, showed a mortality relative risk of 0.73 (95% credible interval 0.52-0.96). When data from 8 observational studies were added to the analysis, the resultant relative risk was 0.72 (credible interval 0.62-0.82). The posterior probability that hormone therapy reduces total mortality in younger women is almost 1.
Conclusions
The synthesis of data using Bayesian meta-analysis indicates a reduction in mortality in younger postmenopausal women taking hormone therapy compared with no treatment. This finding should be interpreted taking into account the potential benefits and harms of hormone therapy.
To read this article in its entirety, please visit our website.
-- Shelley R. Salpeter, MD, Ji Cheng, MSc, Lehana Thabane, PhD, Nicholas S. Buckley, Edwin E. Salpeter, PhD (Posthumous)
This article was originally published in the November 2009 issue of The American Journal of Medicine.
Kamis, 01 Oktober 2009
Alcohol and Illicit Drug Use as Precipitants of Atrial Fibrillation in Young Adults: A Case Series and Literature Review
Alcohol and illicit drugs are associated with atrial fibrillation. Avoidance of these substances can help prevent further paroxysms. Apart from avoidance, there are no existing guidelines on the management of lone atrial fibrillation, precipitated by alcohol/illicit drugs. “Real life” management varies widely.
Abstract
Background
Atrial fibrillation in young patients (≤45 years) is uncommon. There is the perception that the precipitant in such cases is alcohol, but we also have noted cases related to illicit drug abuse. There are no clear guidelines on the treatment of atrial fibrillation in patients presenting with “lone atrial fibrillation” precipitated by alcohol or illicit drugs.
Methods
We retrospectively analyzed young (defined as ≤45 years) patients with “lone” atrial fibrillation who were admitted to the hospital with electrocardiographically confirmed diagnosis of atrial fibrillation or atrial flutter, precipitated by either alcohol or illicit drugs, over a 6-year period.
Results
Eighty-eight patients aged ≤45 years were admitted with atrial fibrillation or atrial flutter. In 22 patients, (mean [SD] age 33.6 [8.4] years; 20 male), alcohol (n = 19) and/or illicit drugs (n = 3) were found to be the precipitant. One patient required electrical cardioversion, with the remaining patients cardioverting back to sinus rhythm either pharmacologically or spontaneously. Twelve (54.5%) were investigated for atrial fibrillation burden by 24-hour Holter monitoring and the majority also underwent a transthoracic echocardiogram (81.8%). At discharge, 14 (63.6%) patients were treated with anti-arrhythmic drugs and 10 received either antiplatelets or anticoagulants. Most (85%) patients were followed-up for at least 12 months, during which time 6 had further paroxysms; all of whom continued to abuse either alcohol or illicit drugs.
Conclusions
Alcohol and illicit drugs are arrhythmogenic and are associated with atrial fibrillation. Apart from abstinence, the optimal management of such patients and the long-term effects of these substances on the heart and atrial fibrillation recurrences are still unclear.
To read this article in its entirety, please visit our website.
-- Suresh Krishnamoorthy, MRCP, Gregory Y.H. Lip, MD, Deirdre A. Lane, PhD
This article was originally published in the September 2009 issue of The American Journal of Medicine.
Abstract
Background
Atrial fibrillation in young patients (≤45 years) is uncommon. There is the perception that the precipitant in such cases is alcohol, but we also have noted cases related to illicit drug abuse. There are no clear guidelines on the treatment of atrial fibrillation in patients presenting with “lone atrial fibrillation” precipitated by alcohol or illicit drugs.
Methods
We retrospectively analyzed young (defined as ≤45 years) patients with “lone” atrial fibrillation who were admitted to the hospital with electrocardiographically confirmed diagnosis of atrial fibrillation or atrial flutter, precipitated by either alcohol or illicit drugs, over a 6-year period.
Results
Eighty-eight patients aged ≤45 years were admitted with atrial fibrillation or atrial flutter. In 22 patients, (mean [SD] age 33.6 [8.4] years; 20 male), alcohol (n = 19) and/or illicit drugs (n = 3) were found to be the precipitant. One patient required electrical cardioversion, with the remaining patients cardioverting back to sinus rhythm either pharmacologically or spontaneously. Twelve (54.5%) were investigated for atrial fibrillation burden by 24-hour Holter monitoring and the majority also underwent a transthoracic echocardiogram (81.8%). At discharge, 14 (63.6%) patients were treated with anti-arrhythmic drugs and 10 received either antiplatelets or anticoagulants. Most (85%) patients were followed-up for at least 12 months, during which time 6 had further paroxysms; all of whom continued to abuse either alcohol or illicit drugs.
Conclusions
Alcohol and illicit drugs are arrhythmogenic and are associated with atrial fibrillation. Apart from abstinence, the optimal management of such patients and the long-term effects of these substances on the heart and atrial fibrillation recurrences are still unclear.
To read this article in its entirety, please visit our website.
-- Suresh Krishnamoorthy, MRCP, Gregory Y.H. Lip, MD, Deirdre A. Lane, PhD
This article was originally published in the September 2009 issue of The American Journal of Medicine.
Incidence of Thrombocytopenia in Hospitalized Patients with Venous Thromboembolism
Although heparin-associated thrombocytopenia is uncommon, the incidence can be minimized by use of low molecular weight heparin, particularly if extended prophylaxis or extended treatment is required.
Abstract
Purpose
To determine the incidence of heparin-associated thrombocytopenia in patients receiving prophylaxis or treatment for venous thromboembolism.
Methods
We assessed the database of the National Hospital Discharge Survey from 1979 through 2005 and complemented this with a meta-analysis of published literature.
Results
Among 10,554,000 patients discharged from short-stay hospitals throughout the US with venous thromboembolism during the 27 years of study, secondary thrombocytopenia was coded in 38,000 patients (0.36%). From 1979 through 1992, secondary thrombocytopenia was coded in only 0.15% of hospitalized patients with venous thromboembolism. The frequency increased sharply to 0.54% from 1993 through 2005. Secondary thrombocytopenia was rarely diagnosed among 1,446,000 patients aged <40 years and among 77,000 women who had venous thromboembolism with deliveries. Meta-analysis of published literature showed a higher incidence among patients who received unfractionated heparin (UFH) for prophylaxis than those who received low-molecular-weight heparin (LMWH) for prophylaxis. Treatment resulted in smaller differences of the incidence between UFH and LMWH.
Conclusion
Heparin-associated thrombocytopenia is rare among patients aged <40 years and women following delivery. The risk of heparin-associated thrombocytopenia is more duration-related than dose-related, and higher with UFH when used for an extended duration. Our findings and those of the literature suggest that although heparin-associated thrombocytopenia is uncommon, the incidence can be minimized by use of LMWH, particularly if extended prophylaxis or extended treatment is required.
To read this article in its entirety, please visit our website.
-- Paul D. Stein, MD, Russell D. Hull, MBBS, MSc, Fadi Matta, MD, Abdo Y. Yaekoub, MDc, Jane Liang, MSc
This article was originally published in the October 2009 issue of The American Journal of Medicine.
Abstract
Purpose
To determine the incidence of heparin-associated thrombocytopenia in patients receiving prophylaxis or treatment for venous thromboembolism.
Methods
We assessed the database of the National Hospital Discharge Survey from 1979 through 2005 and complemented this with a meta-analysis of published literature.
Results
Among 10,554,000 patients discharged from short-stay hospitals throughout the US with venous thromboembolism during the 27 years of study, secondary thrombocytopenia was coded in 38,000 patients (0.36%). From 1979 through 1992, secondary thrombocytopenia was coded in only 0.15% of hospitalized patients with venous thromboembolism. The frequency increased sharply to 0.54% from 1993 through 2005. Secondary thrombocytopenia was rarely diagnosed among 1,446,000 patients aged <40 years and among 77,000 women who had venous thromboembolism with deliveries. Meta-analysis of published literature showed a higher incidence among patients who received unfractionated heparin (UFH) for prophylaxis than those who received low-molecular-weight heparin (LMWH) for prophylaxis. Treatment resulted in smaller differences of the incidence between UFH and LMWH.
Conclusion
Heparin-associated thrombocytopenia is rare among patients aged <40 years and women following delivery. The risk of heparin-associated thrombocytopenia is more duration-related than dose-related, and higher with UFH when used for an extended duration. Our findings and those of the literature suggest that although heparin-associated thrombocytopenia is uncommon, the incidence can be minimized by use of LMWH, particularly if extended prophylaxis or extended treatment is required.
To read this article in its entirety, please visit our website.
-- Paul D. Stein, MD, Russell D. Hull, MBBS, MSc, Fadi Matta, MD, Abdo Y. Yaekoub, MDc, Jane Liang, MSc
This article was originally published in the October 2009 issue of The American Journal of Medicine.
The Patient–Physician–Industry–Government Partnership: A Societal Good
I recently celebrated the 40th anniversary of my graduation from medical school at a class reunion in Boston. While reminiscing with my former classmates about the joys and tribulations of living as a student during the 1960s, a discussion arose regarding what was available to us then in the area of pharmacotherapeutics compared with what is now available for practicing physicians. In regard to treatments for cardiovascular disease, my area of internal medicine subspecialty, we had nitrates for angina pectoris; digitalis preparations and furosemide for heart failure; hydrochlorothiazide, reserpine, guanethidine, hydralazine, and alpha-methyldopa for hypertension; quinidine, lidocaine, and procainamide for arrhythmias; and bile acid resins for hypercholesterolemia. Since 1969, with the advances in basic research supported by the National Institutes of Health (NIH) and the development of new drugs by the pharmaceutical industry, we now have available for clinical use the beta-adrenergic blockers and calcium-entry blockers for the treatment of angina pectoris; angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for heart failure; new drugs for systemic and pulmonary hypertension; thrombolytics for myocardial infarction; statins for hypercholesterolemia; and new antiplatelet drugs. These newer therapies have favorably affected both the prevention and treatment of cardiovascular disease.
As examples, over the past 40 years, major reductions have occurred in the numbers of acute myocardial infarctions, in part related to innovative drug therapies for cholesterol elevations, hypertension, and smoking addiction.
To read this article in its entirety, please visit our website.
- William H. Frishman, MD
This article was originally published in the October 2009 issue of The American Journal of Medicine.
As examples, over the past 40 years, major reductions have occurred in the numbers of acute myocardial infarctions, in part related to innovative drug therapies for cholesterol elevations, hypertension, and smoking addiction.
To read this article in its entirety, please visit our website.
- William H. Frishman, MD
This article was originally published in the October 2009 issue of The American Journal of Medicine.
Kamis, 17 September 2009
Mortality after Hospitalization with Mild, Moderate, and Severe Hyponatremia
Hyponatremia is present on admission in almost 15% of hospitalized patients. Even mild hyponatremia carries a significantly increased risk of death in hospital. The risk of death associated with hyponatremia appears to be particularly strong in patients with cardiovascular disease, cancer, and those undergoing orthopedic procedures.
Abstract
Background
Hyponatremia is the most common electrolyte abnormality in hospitalized individuals.
Methods
To investigate the association between serum sodium concentration and mortality, we conducted a prospective cohort study of 98,411 adults hospitalized between 2000 and 2003 at 2 teaching hospitals in Boston, Massachusetts. The main outcome measures were in-hospital, 1-year, and 5-year mortality. Multivariable logistic regression and Cox proportional hazards models were used to compare outcomes in patients with varying degrees of hyponatremia against those with normal serum sodium concentration.
Results
Hyponatremia (serum sodium concentration <135 mEq/L) was observed in 14.5% of patients on initial measurement. Compared with patients with normonatremia (135-144 mEq/L), those with hyponatremia were older (67.0 vs 63.1 years, P<.001) and had more comorbid conditions (mean Deyo-Charlson Index 1.9 vs 1.4, P <.001). In multivariable-adjusted models, patients with hyponatremia had an increased risk of death in hospital (odds ratio 1.47, 95% confidence interval [CI], 1.33-1.62), at 1 year (hazard ratio 1.38, 95% CI, 1.32-1.46), and at 5 years (hazard ratio 1.25, 95% CI, 1.21-1.30). The increased risk of death was evident even in those with mild hyponatremia (130-134 mEq/L; odds ratio 1.37, 95% CI, 1.23-1.52). The relationship between hyponatremia and mortality was pronounced in patients admitted with cardiovascular disease, metastatic cancer, and those admitted for procedures related to the musculoskeletal system. Resolution of hyponatremia during hospitalization attenuated the increased mortality risk conferred by hyponatremia.
Conclusion
Hyponatremia, even when mild, is associated with increased mortality.
To read this article in its entirety, please visit our website.
-- Sushrut S. Waikar, MD, MPH, David B. Mount, MD, Gary C. Curhan, MD, ScD
This article was originally published in the September 2009 issue of The American Journal of Medicine.
Abstract
Background
Hyponatremia is the most common electrolyte abnormality in hospitalized individuals.
Methods
To investigate the association between serum sodium concentration and mortality, we conducted a prospective cohort study of 98,411 adults hospitalized between 2000 and 2003 at 2 teaching hospitals in Boston, Massachusetts. The main outcome measures were in-hospital, 1-year, and 5-year mortality. Multivariable logistic regression and Cox proportional hazards models were used to compare outcomes in patients with varying degrees of hyponatremia against those with normal serum sodium concentration.
Results
Hyponatremia (serum sodium concentration <135 mEq/L) was observed in 14.5% of patients on initial measurement. Compared with patients with normonatremia (135-144 mEq/L), those with hyponatremia were older (67.0 vs 63.1 years, P<.001) and had more comorbid conditions (mean Deyo-Charlson Index 1.9 vs 1.4, P <.001). In multivariable-adjusted models, patients with hyponatremia had an increased risk of death in hospital (odds ratio 1.47, 95% confidence interval [CI], 1.33-1.62), at 1 year (hazard ratio 1.38, 95% CI, 1.32-1.46), and at 5 years (hazard ratio 1.25, 95% CI, 1.21-1.30). The increased risk of death was evident even in those with mild hyponatremia (130-134 mEq/L; odds ratio 1.37, 95% CI, 1.23-1.52). The relationship between hyponatremia and mortality was pronounced in patients admitted with cardiovascular disease, metastatic cancer, and those admitted for procedures related to the musculoskeletal system. Resolution of hyponatremia during hospitalization attenuated the increased mortality risk conferred by hyponatremia.
Conclusion
Hyponatremia, even when mild, is associated with increased mortality.
To read this article in its entirety, please visit our website.
-- Sushrut S. Waikar, MD, MPH, David B. Mount, MD, Gary C. Curhan, MD, ScD
This article was originally published in the September 2009 issue of The American Journal of Medicine.
Rabu, 16 September 2009
Seriously Stressed
Presentation
Substance abuse—or more likely, its abrupt cessation—was a likely trigger for an unusual cardiac syndrome. A 25-year-old woman was brought to the emergency department from home after a seizure episode. En route to the hospital, the patient lost consciousness, and the emergency medical team discovered that she was in torsades de pointes, which then progressed to ventricular fibrillation. The patient was defibrillated to sinus tachycardia with a monophasic waveform shock of 360 J. She was successfully resuscitated, regained consciousness, and denied any chest pain or shortness of breath. On further questioning, she denied any past history of arrhythmia or family history of sudden cardiac arrest or unexplained death.
Assessment
The patient admitted to daily heavy alcohol consumption, and 3 days before hospitalization, she had used cocaine. Her potassium and magnesium levels on admission were 3.2 mEq/L and 1.4 mg/dL, respectively. An electrocardiogram (ECG) performed 3 hours after resuscitation revealed a narrow complex sinus tachycardia with deep, inverted T waves in leads II, III, AVF, and V3-V6, and a remarkably prolonged QTc interval of more than 660 msec (Figure 1). She was not taking any medications known to prolong the QT interval.
Serial cardiac enzymes remained within the normal range. A chest X-ray and computed tomography of the head were normal. However, a transthoracic echocardiogram disclosed an anteroapical regional wall motion abnormality and a reduced left-ventricular ejection fraction of 35-40%. Coronary angiography was normal. Left ventriculography showed basal hyperkinesis with apical ballooning, a finding consistent with takotsubo cardiomyopathy. The condition also is known as stress cardiomyopathy, because it can be induced by short-term emotional or physiologic stress.
Diagnosis
Our patient's diagnosis of takotsubo cardiomyopathy was based on the following criteria: transient hypokinesis, akinesis, or dyskinesis of the left ventricular apical and mid-ventricular segments; absence of obstructive coronary artery disease; ECG changes, either ST-segment elevation and/or T-wave inversion; and absence of head trauma, intracranial bleeding, pheochromocytoma, hypertrophic obstructive cardiomyopathy, or myocarditis.(1, 2)
To read this article in its entirety, please visit our website.
-- Nishant Kalra, MD, Prashant Khetpal, MD, MPH, Vincent L. Sorrell, MD
This article was originally published in the August 2009 issue of The American Journal of Medicine.
Substance abuse—or more likely, its abrupt cessation—was a likely trigger for an unusual cardiac syndrome. A 25-year-old woman was brought to the emergency department from home after a seizure episode. En route to the hospital, the patient lost consciousness, and the emergency medical team discovered that she was in torsades de pointes, which then progressed to ventricular fibrillation. The patient was defibrillated to sinus tachycardia with a monophasic waveform shock of 360 J. She was successfully resuscitated, regained consciousness, and denied any chest pain or shortness of breath. On further questioning, she denied any past history of arrhythmia or family history of sudden cardiac arrest or unexplained death.
Assessment
The patient admitted to daily heavy alcohol consumption, and 3 days before hospitalization, she had used cocaine. Her potassium and magnesium levels on admission were 3.2 mEq/L and 1.4 mg/dL, respectively. An electrocardiogram (ECG) performed 3 hours after resuscitation revealed a narrow complex sinus tachycardia with deep, inverted T waves in leads II, III, AVF, and V3-V6, and a remarkably prolonged QTc interval of more than 660 msec (Figure 1). She was not taking any medications known to prolong the QT interval.
Serial cardiac enzymes remained within the normal range. A chest X-ray and computed tomography of the head were normal. However, a transthoracic echocardiogram disclosed an anteroapical regional wall motion abnormality and a reduced left-ventricular ejection fraction of 35-40%. Coronary angiography was normal. Left ventriculography showed basal hyperkinesis with apical ballooning, a finding consistent with takotsubo cardiomyopathy. The condition also is known as stress cardiomyopathy, because it can be induced by short-term emotional or physiologic stress.
Diagnosis
Our patient's diagnosis of takotsubo cardiomyopathy was based on the following criteria: transient hypokinesis, akinesis, or dyskinesis of the left ventricular apical and mid-ventricular segments; absence of obstructive coronary artery disease; ECG changes, either ST-segment elevation and/or T-wave inversion; and absence of head trauma, intracranial bleeding, pheochromocytoma, hypertrophic obstructive cardiomyopathy, or myocarditis.(1, 2)
To read this article in its entirety, please visit our website.
-- Nishant Kalra, MD, Prashant Khetpal, MD, MPH, Vincent L. Sorrell, MD
This article was originally published in the August 2009 issue of The American Journal of Medicine.
Jumat, 04 September 2009
Mild Hyponatremia Carries a Poor Prognosis in Community Subjects
Abstract
Objective
Hyponatremia has been shown to predict adverse outcome in congestive heart failure and pneumonia among other common clinical entities, but its significance in the general population is elusive.
Methods
The population-based Copenhagen Holter Study included 671 men and women aged 55 to 75 years with no history of cardiovascular disease, stroke, or cancer. Baseline evaluation included 48-hour ambulatory electrocardiogram monitoring, blood tests, and a questionnaire. Hyponatremia was defined as s-Na ≤ 134 mEq/L or s-Na ≤ 137 mEq/L according to previously accepted definitions. An adverse outcome was defined as deaths or myocardial infarction. Median follow-up was 6.3 years.
Results
Fourteen subjects (2.1%, group A) had s-Na ≤ 134 mEq/L, and 62 subjects (9.2%, group B) had s-Na ≤ 137 mEq/L. No subject had s-Na < 129 mEq/L. An adverse outcome occurred in 43% of group A, 27% of group B, and 14% of subjects with s-Na >137mEq/L (controls) (P <.002). Adjusted hazard ratio for adverse outcome was 3.56 (95% confidence interval [CI], 1.53-8.28, P <.005) in group A compared with controls and 2.21 (95% CI, 1.29-3.80, P <.005) in group B after controlling for age, gender, smoking, diabetes, low-density lipoprotein cholesterol, and blood pressure. The hazard ratios were robust for additional adjusting for variables showing univariate association to hyponatremia (ie, beta-blocker and diuretic use, heart rate variability, creatinine, C-reactive protein, and NT-pro brain natriuretic peptide). By excluding diuretic users (18% of subjects), the adjusted hazard ratio for adverse outcome was 8.00 (95% CI, 3.04-21.0, P <.0001) in group A and 3.17 (95% CI, 1.76-5.72, P = .0001) in group B compared with controls.
Conclusion
Hyponatremia is an independent predictor of deaths and myocardial infarction in middle-aged and elderly community subjects.
To read this article in its entirety, please visit our website
-- Ahmad Sajadieh, MD, DMSc, Zeynep Binici, MD, Mette Rauhe Mouridsen, MD, Olav Wendelboe Nielsen, MD, PhD, DMSc, Jørgen Fischer Hansen, MD, DMSc, Steen B. Haugaard, MD, DMSc
This article was originally published in the July 2009 issue of The American Journal of Medicine.
Objective
Hyponatremia has been shown to predict adverse outcome in congestive heart failure and pneumonia among other common clinical entities, but its significance in the general population is elusive.
Methods
The population-based Copenhagen Holter Study included 671 men and women aged 55 to 75 years with no history of cardiovascular disease, stroke, or cancer. Baseline evaluation included 48-hour ambulatory electrocardiogram monitoring, blood tests, and a questionnaire. Hyponatremia was defined as s-Na ≤ 134 mEq/L or s-Na ≤ 137 mEq/L according to previously accepted definitions. An adverse outcome was defined as deaths or myocardial infarction. Median follow-up was 6.3 years.
Results
Fourteen subjects (2.1%, group A) had s-Na ≤ 134 mEq/L, and 62 subjects (9.2%, group B) had s-Na ≤ 137 mEq/L. No subject had s-Na < 129 mEq/L. An adverse outcome occurred in 43% of group A, 27% of group B, and 14% of subjects with s-Na >137mEq/L (controls) (P <.002). Adjusted hazard ratio for adverse outcome was 3.56 (95% confidence interval [CI], 1.53-8.28, P <.005) in group A compared with controls and 2.21 (95% CI, 1.29-3.80, P <.005) in group B after controlling for age, gender, smoking, diabetes, low-density lipoprotein cholesterol, and blood pressure. The hazard ratios were robust for additional adjusting for variables showing univariate association to hyponatremia (ie, beta-blocker and diuretic use, heart rate variability, creatinine, C-reactive protein, and NT-pro brain natriuretic peptide). By excluding diuretic users (18% of subjects), the adjusted hazard ratio for adverse outcome was 8.00 (95% CI, 3.04-21.0, P <.0001) in group A and 3.17 (95% CI, 1.76-5.72, P = .0001) in group B compared with controls.
Conclusion
Hyponatremia is an independent predictor of deaths and myocardial infarction in middle-aged and elderly community subjects.
To read this article in its entirety, please visit our website
-- Ahmad Sajadieh, MD, DMSc, Zeynep Binici, MD, Mette Rauhe Mouridsen, MD, Olav Wendelboe Nielsen, MD, PhD, DMSc, Jørgen Fischer Hansen, MD, DMSc, Steen B. Haugaard, MD, DMSc
This article was originally published in the July 2009 issue of The American Journal of Medicine.
Kamis, 03 September 2009
Psychiatric Comorbidity and Other Psychological Factors in Patients with “Chronic Lyme Disease”
This study found that misdiagnosis of Lyme disease was common, resulting in repeated and unnecessary antibiotic treatment. Psychiatric comorbidity and other psychological factors were associated with functional outcomes.
Abstract
Background
There is no evidence of current or previous Borrelia burgdorferi infection in most patients evaluated at university-based Lyme disease referral centers. Instead, psychological factors likely exacerbate the persistent diffuse symptoms or “Chronic Multisymptom Illness” (CMI) incorrectly ascribed to an ongoing chronic infection with B. burgdorferi. The objective of this study was to assess the medical and psychiatric status of such patients and compare these findings to those from patients without CMI.
Methods
There were 240 consecutive patients who underwent medical evaluation and were screened for clinical disorders (eg, depression and anxiety) with diagnoses confirmed by structured clinical interviews at an academic Lyme disease referral center in New Jersey. Personality disorders, catastrophizing, and negative and positive affect also were evaluated, and all factors were compared between groups and with functional outcomes.
Results
Of our sample, 60.4% had symptoms that could not be explained by current Lyme disease or another medical condition other than CMI. After adjusting for age and sex, clinical disorders were more common in CMI than in the comparison group (P <.001, odds ratio 3.54, 95% confidence interval, 1.97-6.55), but personality disorders were not significantly more common. CMI patients had higher negative affect, lower positive affect, and a greater tendency to catastrophize pain (P <.001) than did the comparison group. Except for personality disorders, all psychological factors were related to worse functioning. Our explanatory model based on these factors was confirmed.
Conclusions
Psychiatric comorbidity and other psychological factors are prominent in the presentation and outcome of some patients who inaccurately ascribe longstanding symptoms to “chronic Lyme disease.”
To read this article in its entirety, please visit our website.
-- Afton L. Hassett, PsyD, Diane C. Radvanski, MS, Steven Buyske, PhD, Shantal V. Savage, BA, Leonard H. Sigal, MD
This article was originally published in the September 2009 issue of The American Journal of Medicine.
Abstract
Background
There is no evidence of current or previous Borrelia burgdorferi infection in most patients evaluated at university-based Lyme disease referral centers. Instead, psychological factors likely exacerbate the persistent diffuse symptoms or “Chronic Multisymptom Illness” (CMI) incorrectly ascribed to an ongoing chronic infection with B. burgdorferi. The objective of this study was to assess the medical and psychiatric status of such patients and compare these findings to those from patients without CMI.
Methods
There were 240 consecutive patients who underwent medical evaluation and were screened for clinical disorders (eg, depression and anxiety) with diagnoses confirmed by structured clinical interviews at an academic Lyme disease referral center in New Jersey. Personality disorders, catastrophizing, and negative and positive affect also were evaluated, and all factors were compared between groups and with functional outcomes.
Results
Of our sample, 60.4% had symptoms that could not be explained by current Lyme disease or another medical condition other than CMI. After adjusting for age and sex, clinical disorders were more common in CMI than in the comparison group (P <.001, odds ratio 3.54, 95% confidence interval, 1.97-6.55), but personality disorders were not significantly more common. CMI patients had higher negative affect, lower positive affect, and a greater tendency to catastrophize pain (P <.001) than did the comparison group. Except for personality disorders, all psychological factors were related to worse functioning. Our explanatory model based on these factors was confirmed.
Conclusions
Psychiatric comorbidity and other psychological factors are prominent in the presentation and outcome of some patients who inaccurately ascribe longstanding symptoms to “chronic Lyme disease.”
To read this article in its entirety, please visit our website.
-- Afton L. Hassett, PsyD, Diane C. Radvanski, MS, Steven Buyske, PhD, Shantal V. Savage, BA, Leonard H. Sigal, MD
This article was originally published in the September 2009 issue of The American Journal of Medicine.
Rabu, 02 September 2009
“Common Sense Is Not So Common” (What We All Need to Remember) – Part Two
Common Sense Is Not So Common.
Voltaire (Francois Marie Arouet, 1694-1778)
Dictionnaire Philosophique, 1764
This essay is the second of 2 dealing with clinical aphorisms that I have derived during many years of clinical experience. The first part contained 8 items and was published in the August issue of The American Journal of Medicine.
Rule # 9: Physician, heal thyself. The physician should be a model of good health habits for 2 reasons. First, patients are unlikely to follow the advice of someone who they believe is hypocritical. A doctor who smokes cigarettes will hardly be believed when informing patients that they have to stop smoking. Secondly, physicians with poor health habits eventually become patients themselves; it is difficult to be an effective health care provider when one's own health is impaired.
Rule # 10: Respect your fellow health care workers; they are your most important clinical asset. Just as no man is an island, no physician works in isolation. The health care team consists of nurses, physician assistants, technicians, laboratory staff, administrators, and many other individuals who make the health care system run smoothly. It is essential that the physician, as the leader of the clinical team, establish smooth working relationships with the many individuals in that unit. Friction, irritation, and bad humor in the environment lead to poor performance and, in the end, harm the patient. When I was a medical student, Judah Folkman informed my classmates and me that if we had a negative relationship with the nurses in the hospital during our clinical rotations then we would be better off selecting a profession other than medicine (personal communication, Judah Folkman, 1967).
Rule # 11: Admission to an intensive care unit in a tertiary care hospital can be a harrowing experience for the patient. Proof of this aphorism can be obtained easily if one takes an objective and uninvolved look at patients in an intensive care unit setting. Many of these individuals are tied to the bed and connected to a variety of tubes that emerge from nearly every natural orifice as well as many iatrogenic orifices. Patients are often unable to communicate with caregivers because of tracheal intubation. Usually they are given periodic doses of mind-altering substances and often are left by themselves for periods of time even in the intensive care environment. Therefore, it is imperative that we periodically take a step back from the bedside and decide what our goals are for these patients. Is there a reasonable chance that all that is being done to them will result in meaningful survival? If the answer to this last question is “no” or “probably not,” then the time has come to start discussing plans with the patient's family for discontinuing life support.
An important corollary to this aphorism is that many patients in the United States undergo excessive testing in the name of defensive medicine. One example is the excessive numbers of brain computed tomography scans that are performed on patients with minimal head trauma or vague histories of headache. In a similar vein, many patients with atypical chest pain are admitted to coronary care units. Much of this excessive utilization of diagnostic services could be eliminated if physicians took the care to obtain a comprehensive history from the patient and spent a few minutes explaining to the patient why certain tests are being performed and why others are not indicated. Many malpractice lawsuits arise as a result of poor communication between the doctor and the patient and not because of medical errors. Establishing rapport with the patient by taking a careful history—the “careful listening” referred to by William Carlos Williams (1883-1963)—is the physician's best defense against liability risk.
Rule # 12: True, true, and unrelated. This phrase refers to a commonly used form of question on medical knowledge examinations. A series of possibly related entities are presented, and the examinee is asked to pair them and state whether they are related or not with respect to causation. Situations often arise in clinical medicine in which one event or one physical finding occurs in close proximity to a second event or finding. However, these 2 events may be related to each other, or they may have occurred spontaneously without any relationship.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD
This article was originally published in the September 2009 issue of The American Journal of Medicine.
Voltaire (Francois Marie Arouet, 1694-1778)
Dictionnaire Philosophique, 1764
This essay is the second of 2 dealing with clinical aphorisms that I have derived during many years of clinical experience. The first part contained 8 items and was published in the August issue of The American Journal of Medicine.
Rule # 9: Physician, heal thyself. The physician should be a model of good health habits for 2 reasons. First, patients are unlikely to follow the advice of someone who they believe is hypocritical. A doctor who smokes cigarettes will hardly be believed when informing patients that they have to stop smoking. Secondly, physicians with poor health habits eventually become patients themselves; it is difficult to be an effective health care provider when one's own health is impaired.
Rule # 10: Respect your fellow health care workers; they are your most important clinical asset. Just as no man is an island, no physician works in isolation. The health care team consists of nurses, physician assistants, technicians, laboratory staff, administrators, and many other individuals who make the health care system run smoothly. It is essential that the physician, as the leader of the clinical team, establish smooth working relationships with the many individuals in that unit. Friction, irritation, and bad humor in the environment lead to poor performance and, in the end, harm the patient. When I was a medical student, Judah Folkman informed my classmates and me that if we had a negative relationship with the nurses in the hospital during our clinical rotations then we would be better off selecting a profession other than medicine (personal communication, Judah Folkman, 1967).
Rule # 11: Admission to an intensive care unit in a tertiary care hospital can be a harrowing experience for the patient. Proof of this aphorism can be obtained easily if one takes an objective and uninvolved look at patients in an intensive care unit setting. Many of these individuals are tied to the bed and connected to a variety of tubes that emerge from nearly every natural orifice as well as many iatrogenic orifices. Patients are often unable to communicate with caregivers because of tracheal intubation. Usually they are given periodic doses of mind-altering substances and often are left by themselves for periods of time even in the intensive care environment. Therefore, it is imperative that we periodically take a step back from the bedside and decide what our goals are for these patients. Is there a reasonable chance that all that is being done to them will result in meaningful survival? If the answer to this last question is “no” or “probably not,” then the time has come to start discussing plans with the patient's family for discontinuing life support.
An important corollary to this aphorism is that many patients in the United States undergo excessive testing in the name of defensive medicine. One example is the excessive numbers of brain computed tomography scans that are performed on patients with minimal head trauma or vague histories of headache. In a similar vein, many patients with atypical chest pain are admitted to coronary care units. Much of this excessive utilization of diagnostic services could be eliminated if physicians took the care to obtain a comprehensive history from the patient and spent a few minutes explaining to the patient why certain tests are being performed and why others are not indicated. Many malpractice lawsuits arise as a result of poor communication between the doctor and the patient and not because of medical errors. Establishing rapport with the patient by taking a careful history—the “careful listening” referred to by William Carlos Williams (1883-1963)—is the physician's best defense against liability risk.
Rule # 12: True, true, and unrelated. This phrase refers to a commonly used form of question on medical knowledge examinations. A series of possibly related entities are presented, and the examinee is asked to pair them and state whether they are related or not with respect to causation. Situations often arise in clinical medicine in which one event or one physical finding occurs in close proximity to a second event or finding. However, these 2 events may be related to each other, or they may have occurred spontaneously without any relationship.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD
This article was originally published in the September 2009 issue of The American Journal of Medicine.
Vitamin D: Bone and Beyond, Rationale and Recommendations for Supplementation
Abstract
Adequate vitamin D status is necessary and beneficial for health, although deficiency plagues much of the world's population. In addition to reducing the risk for bone disease, vitamin D plays a role in reduction of falls, as well as decreases in pain, autoimmune diseases, cancer, heart disease, mortality, and cognitive function. On the basis of this emerging understanding, improving patients' vitamin D status has become an essential aspect of primary care. Although some have suggested increased sun exposure to increase serum vitamin D levels, this has the potential to induce photoaging and skin cancer, especially in patients at risk for these conditions. Vitamin D deficiency and insufficiency can be both corrected and prevented safely through supplementation.
To read this article in its entirety, please visit our website.
-- Sarah A. Stechschulte, BA, Robert S. Kirsner, MD, PhD, Daniel G. Federman, MD
This article was originally published in the September 2009 issue of The American Journal of Medicine.
Adequate vitamin D status is necessary and beneficial for health, although deficiency plagues much of the world's population. In addition to reducing the risk for bone disease, vitamin D plays a role in reduction of falls, as well as decreases in pain, autoimmune diseases, cancer, heart disease, mortality, and cognitive function. On the basis of this emerging understanding, improving patients' vitamin D status has become an essential aspect of primary care. Although some have suggested increased sun exposure to increase serum vitamin D levels, this has the potential to induce photoaging and skin cancer, especially in patients at risk for these conditions. Vitamin D deficiency and insufficiency can be both corrected and prevented safely through supplementation.
To read this article in its entirety, please visit our website.
-- Sarah A. Stechschulte, BA, Robert S. Kirsner, MD, PhD, Daniel G. Federman, MD
This article was originally published in the September 2009 issue of The American Journal of Medicine.
Jumat, 28 Agustus 2009
Medical Bankruptcy in the United States, 2007: Results of a National Study
In 2001 in 5 states sampled, it was found that medical problems contributed to at least 46.2% of all bankruptcies. Since then, health costs and the numbers of un- and underinsured have increased, and bankruptcy laws have tightened. Despite these factors, medical related bankruptcy increased to 62.1% of all bankruptcies in 2007. Illness and medical bills contribute to a large and increasing share of US bankruptcies.
Abstract
Background
Our 2001 study in 5 states found that medical problems contributed to at least 46.2% of all bankruptcies. Since then, health costs and the numbers of un- and underinsured have increased, and bankruptcy laws have tightened.
Methods
We surveyed a random national sample of 2314 bankruptcy filers in 2007, abstracted their court records, and interviewed 1032 of them. We designated bankruptcies as “medical” based on debtors' stated reasons for filing, income loss due to illness, and the magnitude of their medical debts.
Results
Using a conservative definition, 62.1% of all bankruptcies in 2007 were medical; 92% of these medical debtors had medical debts over $5000, or 10% of pretax family income. The rest met criteria for medical bankruptcy because they had lost significant income due to illness or mortgaged a home to pay medical bills. Most medical debtors were well educated, owned homes, and had middle-class occupations. Three quarters had health insurance. Using identical definitions in 2001 and 2007, the share of bankruptcies attributable to medical problems rose by 49.6%. In logistic regression analysis controlling for demographic factors, the odds that a bankruptcy had a medical cause was 2.38-fold higher in 2007 than in 2001.
Conclusions
Illness and medical bills contribute to a large and increasing share of US bankruptcies.
To read this article in its entirety, please visit our website.
-- David U. Himmelstein, MD, Deborah Thorne, PhD, Elizabeth Warren, JD, Steffie Woolhandler, MD, MPH
This article was originally published in the August 2009 issue of The American Journal of Medicine.
Abstract
Background
Our 2001 study in 5 states found that medical problems contributed to at least 46.2% of all bankruptcies. Since then, health costs and the numbers of un- and underinsured have increased, and bankruptcy laws have tightened.
Methods
We surveyed a random national sample of 2314 bankruptcy filers in 2007, abstracted their court records, and interviewed 1032 of them. We designated bankruptcies as “medical” based on debtors' stated reasons for filing, income loss due to illness, and the magnitude of their medical debts.
Results
Using a conservative definition, 62.1% of all bankruptcies in 2007 were medical; 92% of these medical debtors had medical debts over $5000, or 10% of pretax family income. The rest met criteria for medical bankruptcy because they had lost significant income due to illness or mortgaged a home to pay medical bills. Most medical debtors were well educated, owned homes, and had middle-class occupations. Three quarters had health insurance. Using identical definitions in 2001 and 2007, the share of bankruptcies attributable to medical problems rose by 49.6%. In logistic regression analysis controlling for demographic factors, the odds that a bankruptcy had a medical cause was 2.38-fold higher in 2007 than in 2001.
Conclusions
Illness and medical bills contribute to a large and increasing share of US bankruptcies.
To read this article in its entirety, please visit our website.
-- David U. Himmelstein, MD, Deborah Thorne, PhD, Elizabeth Warren, JD, Steffie Woolhandler, MD, MPH
This article was originally published in the August 2009 issue of The American Journal of Medicine.
Only in America: Bankruptcy Due to Health Care Costs
The article by Himmelstein et al in the August 2009 issue of the The American Journal of Medicine documents that health care expenses were the most common cause of bankruptcy in the United States in 2007, accounting for 62% of US bankruptcies compared with 8% in 1981.
Most bankruptcies occurred in middle-class citizens with health insurance, further evidence that our current health care system, based on for-profit, employment-based health insurance, is not working. Millions of Americans have limited access to health care because they cannot afford health insurance. Millions of others, such as those who have to file for bankruptcy because of health care costs, have inadequate health insurance. It is estimated that 1 in 5 Americans goes without health insurance or has inadequate health insurance.
Why is the United States, one of the richest countries in the world, the only major industrial nation that is unable to provide access to health care to all its citizens? Are there any other nations whose citizens have to declare bankruptcy because of health care expenses?
To read this article in its entirety, please visit our website.
-- James E. Dalen, MD, MPH
This article was originally published in the August 2009 issue of The American Journal of Medicine.
Most bankruptcies occurred in middle-class citizens with health insurance, further evidence that our current health care system, based on for-profit, employment-based health insurance, is not working. Millions of Americans have limited access to health care because they cannot afford health insurance. Millions of others, such as those who have to file for bankruptcy because of health care costs, have inadequate health insurance. It is estimated that 1 in 5 Americans goes without health insurance or has inadequate health insurance.
Why is the United States, one of the richest countries in the world, the only major industrial nation that is unable to provide access to health care to all its citizens? Are there any other nations whose citizens have to declare bankruptcy because of health care expenses?
To read this article in its entirety, please visit our website.
-- James E. Dalen, MD, MPH
This article was originally published in the August 2009 issue of The American Journal of Medicine.
“Common Sense Is Not So Common” (What We All Need to Remember)—Part One
Common Sense Is Not So Common.
Voltaire (Francois Marie Arouet, 1694-1778)
Dictionnaire Philosophique, 1764
This editorial is the second time I have discussed clinical aphorisms that have proved useful for me during more than 30 years of inpatient and outpatient attending at 4 US medical schools. The last time I put this list of aphorisms together, it contained 10 items. The current commentary will be published sequentially in 2 parts with 8 aphorisms in part I and 7 additional items in part II for a total of 15.
Rule 1: Common things occur commonly. I make this point continuously to medical students and residents. Sometimes young clinicians will suggest an unusual diagnosis for a patient with the hope of being the only doctor to make the correct diagnosis. More experienced clinicians believe the correct diagnosis is usually something common. For example, consider a patient with an enlarged spleen. In North America, splenomegaly rarely results from entities such as primary lymphoma of the spleen or malaria. Rather, splenomegaly is often caused by portal hypertension or mononucleosis. One of my first, and best, residents during my internship told me “If it looks like a horse, whinnies like a horse, and smells like a horse, don't expect a zebra to appear” (Stone N, MD, personal communication, 1970).
The experienced clinician is aware of the relative incidence of various illnesses in his/her community, and, unless there are unusual features in a particular patient's clinical picture, one should always seek one of the diagnoses most common in the community where one practices. For example, on moving to Arizona, I was amazed to discover how common coccidiomycosis pneumonia was in our hospital population. I had learned about this illness while studying and working in Boston. However, I had never seen an example of this disease entity and thought that it was a rarity. This is definitely not the case in Arizona where coccidiomycosis pneumonitis is common and should always be considered in the differential diagnosis of a pulmonary infiltrate.
Rule 2: Common sense occurs uncommonly. This aphorism is usually attributed to Voltaire. Over the years, I have seen many violations of this important rule in clinical medicine. Physicians should exercise common sense before ordering tests or performing therapeutic interventions. Examples abound in support of this rule. Recently, I saw a 60-year-old diabetic woman in my office. She had been admitted to our hospital several weeks earlier with a single bout of rest angina. Her cardiac catheterization revealed modest coronary arterial stenoses, and she was placed on medical therapy with brand name medications by another cardiologist: a statin, an angiotensin receptor blocker, and clopidogrel. Subsequently, I first saw her in my office. At that time, she and her family told me that they had paid more than $500 for 1 month's supply of the medicines that had been prescribed in the hospital. I quickly altered her regimen to include generic forms of a statin and an angiotensin-converting enzyme inhibitor, as well as 325 mg of aspirin. These new generic prescriptions would cost the patient less than $20 per month. Common sense should have been used earlier by the inpatient attending physician simply by informing the patient that generic brands cost less than brand name pharmaceuticals. As noted by Harvey Cushing (1869-1939), “Three-fifths of the practice of medicine depends on common sense, knowledge of people and of human reactions.” I would add knowledge of the patient's ability to pay for the medicines prescribed.
Rule 3: The less a procedure is indicated the more likely that its use will be accompanied by complications. This rule advises clinicians to ensure that every procedure or test ordered has a reasonable probability of altering patient management. An example of this aphorism in practice involved a healthy 55-year-old man without coronary heart disease risk factors. He became anxious when a neighbor had an acute myocardial infarction. His doctor suggested that he undergo a coronary calcium computed tomography scan. This test revealed modest coronary calcifications. The patient became more anxious when he heard the results of his computed tomography scan, and he convinced his physician that he needed a coronary angiogram. The angiogram was unremarkable, but the catheterization resulted in a large groin hematoma and pseudoaneurysm that required vascular surgical repair. If I had been involved in this patient's initial care, reassurance or, at most, a Bruce protocol electrocardiographically monitored exercise test, would have been my approach.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD
This article was originally published in the August 2009 issue of The American Journal of Medicine.
Voltaire (Francois Marie Arouet, 1694-1778)
Dictionnaire Philosophique, 1764
This editorial is the second time I have discussed clinical aphorisms that have proved useful for me during more than 30 years of inpatient and outpatient attending at 4 US medical schools. The last time I put this list of aphorisms together, it contained 10 items. The current commentary will be published sequentially in 2 parts with 8 aphorisms in part I and 7 additional items in part II for a total of 15.
Rule 1: Common things occur commonly. I make this point continuously to medical students and residents. Sometimes young clinicians will suggest an unusual diagnosis for a patient with the hope of being the only doctor to make the correct diagnosis. More experienced clinicians believe the correct diagnosis is usually something common. For example, consider a patient with an enlarged spleen. In North America, splenomegaly rarely results from entities such as primary lymphoma of the spleen or malaria. Rather, splenomegaly is often caused by portal hypertension or mononucleosis. One of my first, and best, residents during my internship told me “If it looks like a horse, whinnies like a horse, and smells like a horse, don't expect a zebra to appear” (Stone N, MD, personal communication, 1970).
The experienced clinician is aware of the relative incidence of various illnesses in his/her community, and, unless there are unusual features in a particular patient's clinical picture, one should always seek one of the diagnoses most common in the community where one practices. For example, on moving to Arizona, I was amazed to discover how common coccidiomycosis pneumonia was in our hospital population. I had learned about this illness while studying and working in Boston. However, I had never seen an example of this disease entity and thought that it was a rarity. This is definitely not the case in Arizona where coccidiomycosis pneumonitis is common and should always be considered in the differential diagnosis of a pulmonary infiltrate.
Rule 2: Common sense occurs uncommonly. This aphorism is usually attributed to Voltaire. Over the years, I have seen many violations of this important rule in clinical medicine. Physicians should exercise common sense before ordering tests or performing therapeutic interventions. Examples abound in support of this rule. Recently, I saw a 60-year-old diabetic woman in my office. She had been admitted to our hospital several weeks earlier with a single bout of rest angina. Her cardiac catheterization revealed modest coronary arterial stenoses, and she was placed on medical therapy with brand name medications by another cardiologist: a statin, an angiotensin receptor blocker, and clopidogrel. Subsequently, I first saw her in my office. At that time, she and her family told me that they had paid more than $500 for 1 month's supply of the medicines that had been prescribed in the hospital. I quickly altered her regimen to include generic forms of a statin and an angiotensin-converting enzyme inhibitor, as well as 325 mg of aspirin. These new generic prescriptions would cost the patient less than $20 per month. Common sense should have been used earlier by the inpatient attending physician simply by informing the patient that generic brands cost less than brand name pharmaceuticals. As noted by Harvey Cushing (1869-1939), “Three-fifths of the practice of medicine depends on common sense, knowledge of people and of human reactions.” I would add knowledge of the patient's ability to pay for the medicines prescribed.
Rule 3: The less a procedure is indicated the more likely that its use will be accompanied by complications. This rule advises clinicians to ensure that every procedure or test ordered has a reasonable probability of altering patient management. An example of this aphorism in practice involved a healthy 55-year-old man without coronary heart disease risk factors. He became anxious when a neighbor had an acute myocardial infarction. His doctor suggested that he undergo a coronary calcium computed tomography scan. This test revealed modest coronary calcifications. The patient became more anxious when he heard the results of his computed tomography scan, and he convinced his physician that he needed a coronary angiogram. The angiogram was unremarkable, but the catheterization resulted in a large groin hematoma and pseudoaneurysm that required vascular surgical repair. If I had been involved in this patient's initial care, reassurance or, at most, a Bruce protocol electrocardiographically monitored exercise test, would have been my approach.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD
This article was originally published in the August 2009 issue of The American Journal of Medicine.
It's Time to Bail Out Seniors Trapped in the Medicare Donut Hole!
Medicare D, which became effective in January of 2006, was a major step forward in providing prescription drug coverage to one segment of our population: those age 65 and older. As of 2009, 90% of all seniors (Medicare beneficiaries) had signed up for Medicare D, which is voluntary, or had other insurance coverage for prescription drugs.
The Medicare population accounts for one third of all prescription drug use in the US. The vast majority (87%) of seniors have at least one chronic condition that requires life-long medication, and more than 45% have 3 or more chronic conditions. The average number of prescription drugs for seniors with one of the commonest chronic conditions, congestive heart failure, was 7.5 with an annual cost of $3823 in 2001. The health of our Medicare population is dependent on their being able to afford prescription drugs.
Unfortunately, 2 features of the Medicare D legislation jeopardize the ability of seniors to afford the drugs they require. The legislation forbids Medicare from negotiating drug prices with drug manufacturers. Unlike the Department of Defense, the Veterans Administration, and Medicaid, which are able to negotiate discounts of 30 to 50%, Medicare is forced to pay the manufacturers' asking price. As a result, Medicare and Medicare beneficiaries pay more for prescription drugs than the citizens of any other country. Medicare pays 30% more for prescription drugs than Medicaid pays. In 2 years (2006 and 2007) Medicare paid $3.7 billion more than Medicaid would have paid for the same prescription drugs.
The second feature of the legislation that jeopardizes the ability of seniors to afford prescription drugs is the infamous “donut hole.” Once a deductible of $250 has been paid by the senior, Medicare pays 75% of the cost of drugs and the senior pays 25% until the total amount paid by Medicare and the patient reaches $2250. At that point, the senior pays 100% out of pocket until the total amount paid by the patient and Medicare reaches a catastrophic limit of $5100. After that point has been reached, the senior is freed from the donut hole and Medicare pays 95% of further prescription costs. In one study, only 3%, and in another study, only 4% of seniors falling into the donut hole emerged to receive catastrophic coverage.
To read this article in its entirety, please visit our website.
-- James E. Dalen, MD, MPH
This article was originally published in the July 2009 issue of The American Journal of Medicine.
The Medicare population accounts for one third of all prescription drug use in the US. The vast majority (87%) of seniors have at least one chronic condition that requires life-long medication, and more than 45% have 3 or more chronic conditions. The average number of prescription drugs for seniors with one of the commonest chronic conditions, congestive heart failure, was 7.5 with an annual cost of $3823 in 2001. The health of our Medicare population is dependent on their being able to afford prescription drugs.
Unfortunately, 2 features of the Medicare D legislation jeopardize the ability of seniors to afford the drugs they require. The legislation forbids Medicare from negotiating drug prices with drug manufacturers. Unlike the Department of Defense, the Veterans Administration, and Medicaid, which are able to negotiate discounts of 30 to 50%, Medicare is forced to pay the manufacturers' asking price. As a result, Medicare and Medicare beneficiaries pay more for prescription drugs than the citizens of any other country. Medicare pays 30% more for prescription drugs than Medicaid pays. In 2 years (2006 and 2007) Medicare paid $3.7 billion more than Medicaid would have paid for the same prescription drugs.
The second feature of the legislation that jeopardizes the ability of seniors to afford prescription drugs is the infamous “donut hole.” Once a deductible of $250 has been paid by the senior, Medicare pays 75% of the cost of drugs and the senior pays 25% until the total amount paid by Medicare and the patient reaches $2250. At that point, the senior pays 100% out of pocket until the total amount paid by the patient and Medicare reaches a catastrophic limit of $5100. After that point has been reached, the senior is freed from the donut hole and Medicare pays 95% of further prescription costs. In one study, only 3%, and in another study, only 4% of seniors falling into the donut hole emerged to receive catastrophic coverage.
To read this article in its entirety, please visit our website.
-- James E. Dalen, MD, MPH
This article was originally published in the July 2009 issue of The American Journal of Medicine.
“Hey, Doc, Is It OK for Me to Drink Coffee?”
Many of my patients with coronary artery disease, diabetes, or hypertension have been warned at various times in their lives to avoid caffeinated coffee because they had been informed that drinking caffeinated coffee could result in increased blood pressure, worsening of diabetic control, and might even trigger a myocardial infarction. Some of my patients also worry that drinking caffeinated coffee might cause cancer. This editorial will briefly cite the now-voluminous evidence that caffeinated coffee in moderate doses (1-3 cups per day in some studies and more in other investigations) is not associated with clinically relevant increases in blood pressure, serum cholesterol levels, myocardial infarction, or various malignancies.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD
This article was originally published in the July 2009 issue of The American Journal of Medicine.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD
This article was originally published in the July 2009 issue of The American Journal of Medicine.
The Effect of a Hypertension Self-Management Intervention on Diabetes and Cholesterol Control
Although most chronic disease self-management programs target specific disease outcomes, they may have unintended but beneficial effects on other comorbid chronic conditions.
Abstract
Background
Most patient chronic disease self-management interventions target single-disease outcomes. We evaluated the effect of a tailored hypertension self-management intervention on the unintended targets of glycosylated hemoglobin (HbA1c) and low-density lipoprotein cholesterol (LDL-C).
Methods
We evaluated patients from the Veterans Study to Improve the Control of Hypertension, a 2-year randomized controlled trial. Patients received either a hypertension self-management intervention delivered by a nurse over the telephone or usual care. Although the study focused on hypertension self-management, we compared changes in HbA1c among a subgroup of 216 patients with diabetes and LDL-C among 528 patients with measurements during the study period. Changes in these laboratory values over time were compared between the 2 treatment groups using linear mixed-effects models.
Results
For the patients with diabetes, the hypertension self-management intervention resulted in a 0.46% reduction in HbA1c over 2 years compared with usual care (95% confidence interval, 0.04%-0.89%; P = .03). For LDL-C, there was a minimal 0.9 mg/dL between-group difference that was not statistically significant (95% confidence interval, −7.3-5.6 mg/dL; P = .79).
Conclusions
There was a significant effect of the self-management intervention on the unintended target of HbA1c,but not LDL-C. Chronic disease self-management interventions might have “spill-over” effects on patients' comorbid chronic conditions.
To read this article in its entirety, please visit our website.
-- Benjamin J. Powers, MD, Maren K. Olsen, PhD, Eugene Z. Oddone, MD, MHS, Hayden B. Bosworth, PhD
This article was originally published in the July 2009 issue of The American Journal of Medicine.
Abstract
Background
Most patient chronic disease self-management interventions target single-disease outcomes. We evaluated the effect of a tailored hypertension self-management intervention on the unintended targets of glycosylated hemoglobin (HbA1c) and low-density lipoprotein cholesterol (LDL-C).
Methods
We evaluated patients from the Veterans Study to Improve the Control of Hypertension, a 2-year randomized controlled trial. Patients received either a hypertension self-management intervention delivered by a nurse over the telephone or usual care. Although the study focused on hypertension self-management, we compared changes in HbA1c among a subgroup of 216 patients with diabetes and LDL-C among 528 patients with measurements during the study period. Changes in these laboratory values over time were compared between the 2 treatment groups using linear mixed-effects models.
Results
For the patients with diabetes, the hypertension self-management intervention resulted in a 0.46% reduction in HbA1c over 2 years compared with usual care (95% confidence interval, 0.04%-0.89%; P = .03). For LDL-C, there was a minimal 0.9 mg/dL between-group difference that was not statistically significant (95% confidence interval, −7.3-5.6 mg/dL; P = .79).
Conclusions
There was a significant effect of the self-management intervention on the unintended target of HbA1c,but not LDL-C. Chronic disease self-management interventions might have “spill-over” effects on patients' comorbid chronic conditions.
To read this article in its entirety, please visit our website.
-- Benjamin J. Powers, MD, Maren K. Olsen, PhD, Eugene Z. Oddone, MD, MHS, Hayden B. Bosworth, PhD
This article was originally published in the July 2009 issue of The American Journal of Medicine.
Kamis, 23 Juli 2009
Depression and Clinical Outcomes in Heart Failure: An OPTIMIZE-HF Analysis
Abstract
Background
Depression is a risk factor of excessive morbidity and mortality in heart failure. We examined in-hospital treatment and postdischarge outcomes in hospitalized heart failure patients with a documented history of depression from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure.
Methods
We identified patient factors associated with depression history and evaluated the association of depression with hospital treatments and mortality, and early postdischarge mortality, emergency care, and rehospitalization.
Results
In 48,612 patients from 259 hospitals, depression history was present in 10.6% and occurred more often in females, whites, and those with common heart failure comorbidities, including chronic pulmonary obstructive disease (36% vs 27%), anemia (27% vs 16.5%), insulin-dependent diabetes mellitus (20% vs 16%), and hyperlipidemia (38% vs 31%), all P <.001. Patients with depression history were less likely to receive coronary interventions and cardiac devices, all P <.01; or be referred to outpatient disease management programs, P <.001. Length of hospital stay was longer with depression history (7.0 vs 6.4 days, P <.001). In 5791 patients followed-up at 60-90 days postdischarge, those with depression history had higher mortality (8.8% vs 6.4%; P=.025). After multivariable modeling, depression history remained a predictor of length of hospital stay, P <.001 and postdischarge mortality, P=.02.
Conclusions
Depression history at heart failure hospitalization may be a predictor of prolonged length of hospital stay, less use of cardiac procedures and postdischarge disease management, and increased 60-90 day mortality. Patients with depression might represent a vulnerable group in which improved use of evidence-based treatment should be considered.
To read this article in its entirety, please visit our website.
Nancy M. Albert, PhDa, Gregg C. Fonarow, MDb, William T. Abraham, MDc, Mihai Gheorghiade, MDd, Barry H. Greenberg, MDe, Eduardo Nunez, MDf, Christopher M. O'Connor, MDg, Wendy G. Stough, PharmDh, Clyde W. Yancy, MDi, James B. Young, MDj
This article was originally published in the April 2009 issue of The American Journal of Medicine.
Background
Depression is a risk factor of excessive morbidity and mortality in heart failure. We examined in-hospital treatment and postdischarge outcomes in hospitalized heart failure patients with a documented history of depression from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure.
Methods
We identified patient factors associated with depression history and evaluated the association of depression with hospital treatments and mortality, and early postdischarge mortality, emergency care, and rehospitalization.
Results
In 48,612 patients from 259 hospitals, depression history was present in 10.6% and occurred more often in females, whites, and those with common heart failure comorbidities, including chronic pulmonary obstructive disease (36% vs 27%), anemia (27% vs 16.5%), insulin-dependent diabetes mellitus (20% vs 16%), and hyperlipidemia (38% vs 31%), all P <.001. Patients with depression history were less likely to receive coronary interventions and cardiac devices, all P <.01; or be referred to outpatient disease management programs, P <.001. Length of hospital stay was longer with depression history (7.0 vs 6.4 days, P <.001). In 5791 patients followed-up at 60-90 days postdischarge, those with depression history had higher mortality (8.8% vs 6.4%; P=.025). After multivariable modeling, depression history remained a predictor of length of hospital stay, P <.001 and postdischarge mortality, P=.02.
Conclusions
Depression history at heart failure hospitalization may be a predictor of prolonged length of hospital stay, less use of cardiac procedures and postdischarge disease management, and increased 60-90 day mortality. Patients with depression might represent a vulnerable group in which improved use of evidence-based treatment should be considered.
To read this article in its entirety, please visit our website.
Nancy M. Albert, PhDa, Gregg C. Fonarow, MDb, William T. Abraham, MDc, Mihai Gheorghiade, MDd, Barry H. Greenberg, MDe, Eduardo Nunez, MDf, Christopher M. O'Connor, MDg, Wendy G. Stough, PharmDh, Clyde W. Yancy, MDi, James B. Young, MDj
This article was originally published in the April 2009 issue of The American Journal of Medicine.
Selasa, 21 Juli 2009
Vascular Endothelial Growth Factor in Systemic Capillary Leak Syndrome
Systemic capillary leak syndrome is a rare disorder characterized by acute attacks of severe vascular hyperpermeability causing hypotension and shock. All patients have a paraproteinemia. There is a rarer variant of this syndrome in which the same symptoms appear in a chronic form. The diagnosis is made by exclusion of other causes. The cause has not been elucidated, and no treatment has been shown effective.
To read this article in its entirety, please visit our website.
-- Willem Joost Lesterhuis, MD, Alexander J. Rennings, MD, William P. Leenders, PhD, Arjan Nooteboom, PhD, Cornelis J. Punt, MD, PhD, Fred C. Sweep, PhD, Peter Pickkers, MD, Anneke Geurts-Moespot, MS, Hanneke W. Van Laarhoven, MD, PhD, Johan Van der Vlag, PhD, Jo H. Berden, MD, PhD, Cor T. Postma, MD, Phd, Jos W. Van der Meer, MD, PhD
This article was originally published in the June 2009 issue of The American Journal of Medicine.
To read this article in its entirety, please visit our website.
-- Willem Joost Lesterhuis, MD, Alexander J. Rennings, MD, William P. Leenders, PhD, Arjan Nooteboom, PhD, Cornelis J. Punt, MD, PhD, Fred C. Sweep, PhD, Peter Pickkers, MD, Anneke Geurts-Moespot, MS, Hanneke W. Van Laarhoven, MD, PhD, Johan Van der Vlag, PhD, Jo H. Berden, MD, PhD, Cor T. Postma, MD, Phd, Jos W. Van der Meer, MD, PhD
This article was originally published in the June 2009 issue of The American Journal of Medicine.
Kamis, 16 Juli 2009
Who is the worlds fattest man over 90 years old?
I interrupt this blog for this important question:
Who is the worlds fattest man over 90 years old?
I just read a review of an article from the respected "Science Magazine" that told of a long term scientific experiment with rhesus monkeys. It said that those monkeys on a resctricted diet not only live longer but they show far fewer signs of aging in both their bodies and brains. This got me thinking about finding the oldest person I could find who was at least 300 pounds overweight.
I scanned the internet and found lots of super- heavyweights but they were all relatively young. Think of it. The average life expectancy for men is at least in the middle 70's to 80's. Many people are now living to see 100. And the question is do fat people make it to those higher ages?
Or are many people who live into upper old age those who have changed their eating habits and gotten slimmer? I've looked and I didn't find too many obese elderly in the nursing homes I've visited.
If you know of super-heavyweights in their 90's and above let me know. In the meantime I've posted some exerpts from the review article I saw about the monkeys so you can have another reason, another incentive to get with your diet program and stick to it.
Write me Erwin RF. Send your email to brownbagdiet@gmail.com
Shattering Myths
Many centenarians are remarkably robust. The New England Centenarian Study (NECS), initially a collaboration between Harvard Medical School and Beth Israel Deaconess Medical Center, now moved to Boston University Medical Center, has found that:
One quarter of the 169 study subjects—all of whom were at least 100—were completely free of any significant cognitive disorders and even surpassed the research interviewers on some mental tests.
Fifteen percent still lived independently in their own homes.
Some still held jobs.
Medical expenses for centenarians are significantly lower than for those in their sixties and seventies.
Most are uncommonly healthy until the very end of their lives.
Conventional wisdom says people inevitably decline into worsening health and senility when they reach their eighties, nineties, and beyond. In reality, centenarians, 80% of whom are women, are actually healthier as a group than people 20 years their junior. They have somehow managed to weather the stresses of life and avoid major threats like heart disease, cancer, and Alzheimer's disease.
Good Genes, Stress-Resistance, and Determination
Researchers are beginning to understand how centenarians reach this amazing milestone. In their book describing the NECS, Thomas Perls, MD, and Margery Silver, MD, point to characteristics shared by most of the 169 people they studied:
Good longevity genes
Emotional resilience—ability to adapt to life's events
Resistance to stress—excellent coping skills
Self-sufficiency
Intellectual activity
Good sense of humor, including about themselves
Religious beliefs
Strong connections with other people
Low blood pressure
Appreciation of simple pleasures and experiences
Women tend to have borne children after age 40
Zest for life
Don't currently smoke or drink heavily
Many play musical instruments
Follow an anti-inflammatory diet that has been linked with longevity (eg, Mediterranean diet)
Some Are Genetically Privileged
If any of your parents, grandparents, aunts, uncles and siblings have lived to extreme old age and if your family has a low incidence of diseases like cancer, Alzheimer's, diabetes, and heart disease—congratulations! You are considered to have optimal anti-aging genes and have a great chance to make it to 100 if you take reasonable care of yourself.
Tips for a Longer, Healthier Life
"The average person is born with strong enough longevity genes to live to 85 and maybe longer," Dr. Perls believes. "People who take appropriate preventive steps may add as many as ten quality years to that. The vast majority of baby boomers do a terrible job preparing for old age," he continues. Many consume high fat diets, smoke, drink excessively, and don't exercise.
We have great potential to extend our lives, researchers say, if we just take care of ourselves.
Tune Up Your Attitude
Reduce stress—Try meditation, exercise, or yoga. You can learn to modify your responses to negative situations even if you can't change your basic personality
Stay connected with other people—Social support is vital and maintaining close relationships is associated with better physical and mental health.
Cultivate optimism—A Mayo Clinic study shows that optimists live longer and have better health, because pessimism may lower immune system responsiveness and enhance tumor growth. Good news: an excessively pessimistic outlook on life is changeable. Brief programs can change your thinking about life events and lower the risk for physical illness and even death.
Watch Your Diet
Emphasize fruits and vegetables, whole grains, fiber, and polyunsaturated fats.
Avoid cholesterol, saturated fat, and hydrogenated fat (red meat, egg yolks, fast food burgers, and fries, etc), which are linked to heart disease, breast cancer, and prostate cancer.
Avoid refined sugar and excessive calorie intake.
Avoid processed foods and those supplemented with high fructose corn syrup.
One glass of red wine a day still appears to lower the risk of heart disease.
Drink green tea, which has antioxidants that may fight cancers.
Consider taking antioxidant supplements like vitamin C, vitamin E, and selenium. But if you choose this path, be sure to follow the medical literature on vitamin risks.
Consider supplementing your diet with omega 3 fatty acids.
Exercise: Even a Little Helps
Many of the centenarians in the NECS had lived in second and third floor apartments of three-family houses. This afforded them a perfect opportunity for daily weight-bearing exercise—walking stairs—which builds muscle mass.
Just 15-30 minutes a day of walking or bicycling is enough to gain longevity benefits and reduce the risk of heart disease and cancer. Resistance exercise—for example, walking up stairs or hills—guards against loss of muscle mass and benefits the heart. Exercise also provides a sense of well-being and helps maintain an agile and alert brain.
Use Your Head
According to the NECS researchers, retaining cognitive capacity "most often determines whether people can attain extreme old age while remaining active." Here is a sampling of mental workouts that can keep the brain razor-sharp as you age:
Crossword and jigsaw puzzles
Playing bridge
Learning foreign languages
Playing musical instruments
Learning dance steps
Writing
Sports, including yoga and tai chi
Taking classes
Traveling
Memory training
Experiencing the new and unfamiliar
Floss Your Teeth!
You heard right. Flossing may help prevent heart disease. The last of Dr. Perls' pearls cites preliminary evidence that inflamed gums release substances into the bloodstream that cause clogged arteries. Whether or not it will help you live longer, flossing keeps your gums healthy, prevents tooth loss, and—with all those shining teeth—gives you a nicer smile, too.
DISCUSSION
There are many factors accounting for the longevity of centenarians, inclu ding congenital factors (heredity) and acquired factors such as environment, m ental state, diet and nutrition, physical exercise, life style and behavior. Am ong these factors, diet and nutrition are important in building immunity and in affecting the occurrence of angiocardiopathy, cerebrovascular diseases and malig nant tumors.
As shown in Table 1, the staple foods of the centenarians were low in calories, protein and fat, but high in fiber and rich in mineral substances. Their foods equate to 1419kCal/d, although it suggested that adults taking part in man ual labor need an average 3000kCal/d. According to the FAO/WHO, a 30% decreas e is suggested for persons above the age of 70,£Û2£Ýwhich means that 2100kCal/ d is needed for centenarians. There is a significant difference between these t wo figures (P<0. 01). The daily consumption of protein and fat of cente narians is low (P<0. 01) compared to the standards of modern nutrition. Thi s may be one of the factors which lead to longevity, but its mechanism remains u nknown.
The typical diet of Japanese centenarians shows dried sweet potato slices as the ir main staple food which is very similar to the diet of Chinese centenarians, leading to the question of whether dried sweet potato slices play a role in pro moting good health and long life. Dried sweet potato slices contain low fat, hi gh fiber and are rich in mineral substances. Among various cereals, the sweet p otato is low in calories. This factor may slow down the occurrence of arteriosc lerosis and avoid the ossurrence of life threatening diseases such as angiocardi opathy, cerebrovascular diseases and maligmant tumors.
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Newsweek: How to Live to 100
Newsweek
How to Live to 100Decrepitude isn’t inevitable. New research shows we all have the tools to live longer lives and die faster deaths.June 30, 1997
By Geoffrey Cowley
At 104, Angeline Strandal doesn’t place much stock in doctors. “If they start poking around you,” she says, “they’ll only make you sick.” The Massachusetts centenarian does go in for a physical once in a while, but she hasn’t been seriously ill since the time she came down with appendicitis–in 1925. “People ask me what I eat,” she says. “I’m a vegetarian, more or less. I never smoked. I don’t drink either. That’s one of my good qualities. And I keep my bedroom window open 365 days a year.” Strandal has outlived 11 siblings and a husband, who died back in 1931, but she still cooks every day except Sunday for her 67-year-old daughter and her 69-year-old son. She also catches a daily mass on TV, roots faithfully for the Boston Red Sox and loves nothing more than a good heavyweight fight. “Every day I ask God to give me one more day,” she muses. “And believe it or not, he does.”
We baby boomers may soon find ourselves emulating Angeline Strandal, or someone like her, as devoutly as we once did Jim Morrison. We’ve watched our parents or grandparents die in their 70s–often sick, lonely and helpless–and we’re beginning to sense that life should be longer and richer than that. “When the boomers started turning 50, it was like the start of the Oklahoma land rush,” says Dan Perry, director of the Washington-based Alliance for Aging Research. Surveys by Perry’s organization suggest that today’s 50-year-olds are suddenly serious about living to 100, and keen to get there in reasonably good health.
“They don’t want to spend any time at all in a nursing home,” he says. “The fear of losing independence and the ability to fend for oneself is overwhelming.”
Well, it turns out we may have a say in the matter. A growing body of research suggests that chronic illness is not an inevitable consequence of aging, as we’ve long believed, but more often the result of lifestyle choices that we’re perfectly free to reject. “People used to say, ‘Who would want to be 100?’ ” says Dr. Thomas Perls, an instructor at Harvard Medical School and director of the New England Centenarian Study. “Now they’re realizing it’s an opportunity.” So are booksellers and magazine publishers. “Live long, die fast,” the dust jackets urge us. “Dare to be 100.” Many of us will fall short of that number simply through bad genes or bad luck. And high-tech medicine isn’t likely to change the outlook dramatically; drugs and surgery can do only so much to sustain a body once it starts to fail. But there is no question we can lengthen our lives while shortening our deaths. The tools already exist, and they’re within virtually everyone’s reach.
Life expectancy in the United States has nearly doubled since Angeline Strandal was a kid–from 47 years to 76 years. And though centenarians are still rare, they now constitute the fastest-growing segment of the U.S. population. Their ranks have increased 16-fold over the past six decades–from 3,700 in 1940 to roughly 61,000 today. And the explosion is just getting started. The Census Bureau projects that one in nine baby boomers (9 million of the 80 million people born between 1946 and 1964) will survive into their late 90s, and that one in 26 (or 3 million) will reach 100. “A century ago, the odds of living that long were about one in 500,” says Lynn Adler, founder of the National Centenarian Awareness Project and the author of “Centenarians: The Bonus Years.” “That’s how far we’ve come.” If decrepitude were an inevitable part of aging, these burgeoning numbers would spell trouble. But the evidence suggests that Americans are living better, as well as longer. The disability rate among people older than 65 has fallen steadily since the early 1980s, according to Duke University demographer Kenneth Manton, and a shrinking percentage of seniors are plagued by hypertension, arteriosclerosis and dementia. Moreover, researchers have found that the oldest of the old often enjoy better health than people in their 70s. The 79 centenarians in Perls’s New England study have all lived independently through their early 90s, taking an average of just one medication. And when the time comes for these hearty souls to die, they don’t linger. In a 1995 study, James Lubitz of the Health Care Financing Administration calculated that medical expenditures for the last two years of life–statistically the most expensive–average ">2,600 for people who die at 70, but just $8,300 for those who make it past 100.
These insights have spawned a revolution in the science of aging. “Until recently, there was so much preoccupation with disease that little work was done on the characteristics that permit people to do well,” says Dr. John Rowe, the New York geriatrician who heads the MacArthur Foundation’s Research Network on Successful Aging. Over the past decade, Rowe’s group and others have published hundreds of studies elucidating the factors that help people glide through their later years with clear minds and strong bodies. The research confirms the old saw that it pays to choose your parents well. But the way we age depends less on who we are than on how we live–what we eat, how much we exercise and how we employ our minds.
The Magic of Exercise
Suppose there was a potion that could keep you strong and trim as you aged, while protecting your heart and bones; improving your mood, sleep and memory; warding off breast and colon cancer, and reducing your overall risk of dying prematurely.
Respectable studies have shown that exercise can have all those benefits–even for people who take it up late in life. Experts now agree that most of the physical decline that older people suffer stems not from age but from simple disuse. When we sit all day, year after year, our bones, muscles and organ systems atrophy. But exercise can preserve and even revive them.
When Dr. Ralph Paffenbarger started tracking the health of 19,000 Harvard and University of Pennsylvania alumni back in the early 1960s, many experts thought vigorous exercise was downright dangerous for people over 50. But by monitoring the volunteers’ activity levels and health status over the years, the Stanford epidemiologist turned that wisdom on its head. In a landmark 1986 study, Paffenbarger showed that the participants’ death rates fell in direct proportion to the number of calories they burned each week. Those burning 2,000 a week (roughly the number it takes to walk 20 miles) suffered only half the annual mortality of the couch potatoes, thanks mainly to a lower rate of heart disease.
The alumni study wasn’t set up to gauge the benefits of any particular exercise regimen, but subsequent studies have shown that different activities bring different rewards. Everyone now agrees that aerobic exercise preserves the heart, lungs and brain. And researchers at Tufts University have recently shown that weight lifting can do as much for the frail elderly as it does for high-school jocks. When Dr. Maria Fiatarone got 10 chronically ill nursing-home residents to lift weights three times a week for two months, the participants’ average walking speed nearly tripled, and their balance improved by half. Two had the audacity to throw away their canes.
Miriam Nelson, another Tufts researcher, has since shown how a series of simple strength-training exercises could help keep women from resorting to canes in the first place. She recruited 40 volunteers–all past menopause, none taking estrogen–and split them into two groups. Half continued life as usual, while the other half went to Tufts twice a week to pump iron. Over the course of a year, the women in the control group suffered a predictable loss of bone density, but the weight lifters enjoyed slight increases. They didn’t lose weight (that wasn’t the goal), but they lost fat, and many ended up measurably stronger than their daughters, who were 30 to 40 years younger. Dorothy Barron, who was 64 when she joined Nelson’s experiment, says the experience not only remodeled her body but gave her more energy and confidence than she had had since her youth. Five years later, she still lifts weights–and she has added power walking, horseback riding and white-water rafting to her hobbies. When people ask why she pushes herself so hard, she replies, “I’m too old not to.”
Eating to Nourish Long Life
We all know that living on fat, salt and empty calories can have a range of nasty consequences, from obesity and impotence to hypertension and heart disease. Yet we seem to forget that there are other ways to eat, and that people who adopt them stay younger longer. George and Gaynel Couron will never forget that lesson. The Sacramento, Calif., couple gave up eating meat back in the early 1920s, when they became Seventh-day Adventists. They eventually strayed from the church and its dietary edicts, but they returned to both in 1943, when George suffered a heart attack. Today he’s 100 years old, and Gaynel is 98. They’ve been married for 81 years and have 14 kids ranging in age from 58 to 80. They have slowed down a bit (they’re not planning any more children), but George still takes great delight in growing and eating his own tomatoes, melons, beets, squash and black-eyed peas. As he puts it, “We’re still perking along.” No one can say exactly what role food has played in the Courons’ good fortune, but the age-reversing effects of a plant-based diet are not in question. In controlled studies, San Francisco cardiologist Dean Ornish has shown that a diet based on low-fat, nutrient-rich foods not only prevents heart disease–the Western world’s leading cause of early death–but can help reverse it. And other studies suggest that dietary changes could virtually eliminate the high blood pressure that places 50 million older Americans at high risk of stroke, heart attack and kidney failure.
“Hypertension is not an inevitable part of aging,” says Dr. Boyd Eaton, an Atlanta-based radiologist who has written extensively on nutrition and chronic illness. “It’s a disease of civilization.” You wouldn’t know that from watching people age in this country. Hypertension afflicts a third of all Americans in their 50s, half of those in their 60s and more than two thirds of those over 70. But preindustrial people don’t follow that pattern. Whether they happen to live in China or Africa, Alaska or the Amazon, people in primitive settings experience no change in blood pressure as they age, and the reason is fairly simple: they don’t eat processed foods. Dr. Paul Whelton of Tulane University’s School of Public Health has spent the past decade tracking 15,000 indigenous Yi people in southwestern China. As long as they eat a traditional diet–rice, a little meat and a lot of fresh fruits and vegetables–these rural farmers virtually never develop hypertension. But when they migrate to nearby towns, their blood pressure starts to rise with age. “Their genes don’t change when they move,” Whelton says. “Their diet does.”
What makes processed food so harmful? Salt is one key suspect. When you subsist mainly on fresh plant foods–as our ancestors did for roughly 7 million years–you get 10 times more potassium than sodium. That 10-to-one ratio is, by Eaton’s reasoning, the one our bodies are designed for. But salt is now showered on foods at every stage of processing and preparation (a 4-ounce tomato contains 9 mg of sodium, 4 ounces of bottled tomato sauce nearly 700 mg), while potassium leaches out. As a result, most of us now consume more salt than potassium. “Modern humans are the only mammals that do that,” says Eaton, “and we’re the only ones that develop hypertension.” Correcting that imbalance takes some effort, but it doesn’t require moving to the bush. In fact a recent clinical study suggests that dietary changes can reduce blood pressure as markedly as drug treatment, and can produce results in as little as two months. In the study (known as DASH, or Dietary Approaches to Stop Hypertension), researchers at several institutions placed volunteers on one of three diets. Those on a low-fat menu that included 10 daily servings of fresh fruits and vegetables, plus two servings of calcium-rich dairy products, reduced their systolic and diastolic readings by 5.5 mm and 3.0 mm, respectively. And those suffering from hypertension got reductions of twice that magnitude. “We suspected this was possible,” says nutritionist Eva Obarzanek of the National Heart, Lung and Blood Institute, the federal agency that sponsored the study. “Now we know the size of the effect.”
Researchers have since shown that a simple potassium supplement can bring similar if less dramatic benefits. That’s worth knowing, but keep in mind that potassium is just one of countless age fighters found in real food. The antioxidant vitamins in a tomato or a green leaf can help boost immunity and slow the corrosion of aging cell membranes, and the B vitamins may help protect your heart. By eating plants, you also bathe yourself in cancer-fighting phytochemicals, bone-saving calcium and the fiber needed to maintain the colon and modulate blood sugar. Best of all, you can down them by the bushel without getting fat.
If they do I'd like to find out about it. Send me their stories.
Who is the worlds fattest man over 90 years old?
I just read a review of an article from the respected "Science Magazine" that told of a long term scientific experiment with rhesus monkeys. It said that those monkeys on a resctricted diet not only live longer but they show far fewer signs of aging in both their bodies and brains. This got me thinking about finding the oldest person I could find who was at least 300 pounds overweight.
I scanned the internet and found lots of super- heavyweights but they were all relatively young. Think of it. The average life expectancy for men is at least in the middle 70's to 80's. Many people are now living to see 100. And the question is do fat people make it to those higher ages?
Or are many people who live into upper old age those who have changed their eating habits and gotten slimmer? I've looked and I didn't find too many obese elderly in the nursing homes I've visited.
If you know of super-heavyweights in their 90's and above let me know. In the meantime I've posted some exerpts from the review article I saw about the monkeys so you can have another reason, another incentive to get with your diet program and stick to it.
Write me Erwin RF. Send your email to brownbagdiet@gmail.com
Shattering Myths
Many centenarians are remarkably robust. The New England Centenarian Study (NECS), initially a collaboration between Harvard Medical School and Beth Israel Deaconess Medical Center, now moved to Boston University Medical Center, has found that:
One quarter of the 169 study subjects—all of whom were at least 100—were completely free of any significant cognitive disorders and even surpassed the research interviewers on some mental tests.
Fifteen percent still lived independently in their own homes.
Some still held jobs.
Medical expenses for centenarians are significantly lower than for those in their sixties and seventies.
Most are uncommonly healthy until the very end of their lives.
Conventional wisdom says people inevitably decline into worsening health and senility when they reach their eighties, nineties, and beyond. In reality, centenarians, 80% of whom are women, are actually healthier as a group than people 20 years their junior. They have somehow managed to weather the stresses of life and avoid major threats like heart disease, cancer, and Alzheimer's disease.
Good Genes, Stress-Resistance, and Determination
Researchers are beginning to understand how centenarians reach this amazing milestone. In their book describing the NECS, Thomas Perls, MD, and Margery Silver, MD, point to characteristics shared by most of the 169 people they studied:
Good longevity genes
Emotional resilience—ability to adapt to life's events
Resistance to stress—excellent coping skills
Self-sufficiency
Intellectual activity
Good sense of humor, including about themselves
Religious beliefs
Strong connections with other people
Low blood pressure
Appreciation of simple pleasures and experiences
Women tend to have borne children after age 40
Zest for life
Don't currently smoke or drink heavily
Many play musical instruments
Follow an anti-inflammatory diet that has been linked with longevity (eg, Mediterranean diet)
Some Are Genetically Privileged
If any of your parents, grandparents, aunts, uncles and siblings have lived to extreme old age and if your family has a low incidence of diseases like cancer, Alzheimer's, diabetes, and heart disease—congratulations! You are considered to have optimal anti-aging genes and have a great chance to make it to 100 if you take reasonable care of yourself.
Tips for a Longer, Healthier Life
"The average person is born with strong enough longevity genes to live to 85 and maybe longer," Dr. Perls believes. "People who take appropriate preventive steps may add as many as ten quality years to that. The vast majority of baby boomers do a terrible job preparing for old age," he continues. Many consume high fat diets, smoke, drink excessively, and don't exercise.
We have great potential to extend our lives, researchers say, if we just take care of ourselves.
Tune Up Your Attitude
Reduce stress—Try meditation, exercise, or yoga. You can learn to modify your responses to negative situations even if you can't change your basic personality
Stay connected with other people—Social support is vital and maintaining close relationships is associated with better physical and mental health.
Cultivate optimism—A Mayo Clinic study shows that optimists live longer and have better health, because pessimism may lower immune system responsiveness and enhance tumor growth. Good news: an excessively pessimistic outlook on life is changeable. Brief programs can change your thinking about life events and lower the risk for physical illness and even death.
Watch Your Diet
Emphasize fruits and vegetables, whole grains, fiber, and polyunsaturated fats.
Avoid cholesterol, saturated fat, and hydrogenated fat (red meat, egg yolks, fast food burgers, and fries, etc), which are linked to heart disease, breast cancer, and prostate cancer.
Avoid refined sugar and excessive calorie intake.
Avoid processed foods and those supplemented with high fructose corn syrup.
One glass of red wine a day still appears to lower the risk of heart disease.
Drink green tea, which has antioxidants that may fight cancers.
Consider taking antioxidant supplements like vitamin C, vitamin E, and selenium. But if you choose this path, be sure to follow the medical literature on vitamin risks.
Consider supplementing your diet with omega 3 fatty acids.
Exercise: Even a Little Helps
Many of the centenarians in the NECS had lived in second and third floor apartments of three-family houses. This afforded them a perfect opportunity for daily weight-bearing exercise—walking stairs—which builds muscle mass.
Just 15-30 minutes a day of walking or bicycling is enough to gain longevity benefits and reduce the risk of heart disease and cancer. Resistance exercise—for example, walking up stairs or hills—guards against loss of muscle mass and benefits the heart. Exercise also provides a sense of well-being and helps maintain an agile and alert brain.
Use Your Head
According to the NECS researchers, retaining cognitive capacity "most often determines whether people can attain extreme old age while remaining active." Here is a sampling of mental workouts that can keep the brain razor-sharp as you age:
Crossword and jigsaw puzzles
Playing bridge
Learning foreign languages
Playing musical instruments
Learning dance steps
Writing
Sports, including yoga and tai chi
Taking classes
Traveling
Memory training
Experiencing the new and unfamiliar
Floss Your Teeth!
You heard right. Flossing may help prevent heart disease. The last of Dr. Perls' pearls cites preliminary evidence that inflamed gums release substances into the bloodstream that cause clogged arteries. Whether or not it will help you live longer, flossing keeps your gums healthy, prevents tooth loss, and—with all those shining teeth—gives you a nicer smile, too.
DISCUSSION
There are many factors accounting for the longevity of centenarians, inclu ding congenital factors (heredity) and acquired factors such as environment, m ental state, diet and nutrition, physical exercise, life style and behavior. Am ong these factors, diet and nutrition are important in building immunity and in affecting the occurrence of angiocardiopathy, cerebrovascular diseases and malig nant tumors.
As shown in Table 1, the staple foods of the centenarians were low in calories, protein and fat, but high in fiber and rich in mineral substances. Their foods equate to 1419kCal/d, although it suggested that adults taking part in man ual labor need an average 3000kCal/d. According to the FAO/WHO, a 30% decreas e is suggested for persons above the age of 70,£Û2£Ýwhich means that 2100kCal/ d is needed for centenarians. There is a significant difference between these t wo figures (P<0. 01). The daily consumption of protein and fat of cente narians is low (P<0. 01) compared to the standards of modern nutrition. Thi s may be one of the factors which lead to longevity, but its mechanism remains u nknown.
The typical diet of Japanese centenarians shows dried sweet potato slices as the ir main staple food which is very similar to the diet of Chinese centenarians, leading to the question of whether dried sweet potato slices play a role in pro moting good health and long life. Dried sweet potato slices contain low fat, hi gh fiber and are rich in mineral substances. Among various cereals, the sweet p otato is low in calories. This factor may slow down the occurrence of arteriosc lerosis and avoid the ossurrence of life threatening diseases such as angiocardi opathy, cerebrovascular diseases and maligmant tumors.
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Newsweek: How to Live to 100
Newsweek
How to Live to 100Decrepitude isn’t inevitable. New research shows we all have the tools to live longer lives and die faster deaths.June 30, 1997
By Geoffrey Cowley
At 104, Angeline Strandal doesn’t place much stock in doctors. “If they start poking around you,” she says, “they’ll only make you sick.” The Massachusetts centenarian does go in for a physical once in a while, but she hasn’t been seriously ill since the time she came down with appendicitis–in 1925. “People ask me what I eat,” she says. “I’m a vegetarian, more or less. I never smoked. I don’t drink either. That’s one of my good qualities. And I keep my bedroom window open 365 days a year.” Strandal has outlived 11 siblings and a husband, who died back in 1931, but she still cooks every day except Sunday for her 67-year-old daughter and her 69-year-old son. She also catches a daily mass on TV, roots faithfully for the Boston Red Sox and loves nothing more than a good heavyweight fight. “Every day I ask God to give me one more day,” she muses. “And believe it or not, he does.”
We baby boomers may soon find ourselves emulating Angeline Strandal, or someone like her, as devoutly as we once did Jim Morrison. We’ve watched our parents or grandparents die in their 70s–often sick, lonely and helpless–and we’re beginning to sense that life should be longer and richer than that. “When the boomers started turning 50, it was like the start of the Oklahoma land rush,” says Dan Perry, director of the Washington-based Alliance for Aging Research. Surveys by Perry’s organization suggest that today’s 50-year-olds are suddenly serious about living to 100, and keen to get there in reasonably good health.
“They don’t want to spend any time at all in a nursing home,” he says. “The fear of losing independence and the ability to fend for oneself is overwhelming.”
Well, it turns out we may have a say in the matter. A growing body of research suggests that chronic illness is not an inevitable consequence of aging, as we’ve long believed, but more often the result of lifestyle choices that we’re perfectly free to reject. “People used to say, ‘Who would want to be 100?’ ” says Dr. Thomas Perls, an instructor at Harvard Medical School and director of the New England Centenarian Study. “Now they’re realizing it’s an opportunity.” So are booksellers and magazine publishers. “Live long, die fast,” the dust jackets urge us. “Dare to be 100.” Many of us will fall short of that number simply through bad genes or bad luck. And high-tech medicine isn’t likely to change the outlook dramatically; drugs and surgery can do only so much to sustain a body once it starts to fail. But there is no question we can lengthen our lives while shortening our deaths. The tools already exist, and they’re within virtually everyone’s reach.
Life expectancy in the United States has nearly doubled since Angeline Strandal was a kid–from 47 years to 76 years. And though centenarians are still rare, they now constitute the fastest-growing segment of the U.S. population. Their ranks have increased 16-fold over the past six decades–from 3,700 in 1940 to roughly 61,000 today. And the explosion is just getting started. The Census Bureau projects that one in nine baby boomers (9 million of the 80 million people born between 1946 and 1964) will survive into their late 90s, and that one in 26 (or 3 million) will reach 100. “A century ago, the odds of living that long were about one in 500,” says Lynn Adler, founder of the National Centenarian Awareness Project and the author of “Centenarians: The Bonus Years.” “That’s how far we’ve come.” If decrepitude were an inevitable part of aging, these burgeoning numbers would spell trouble. But the evidence suggests that Americans are living better, as well as longer. The disability rate among people older than 65 has fallen steadily since the early 1980s, according to Duke University demographer Kenneth Manton, and a shrinking percentage of seniors are plagued by hypertension, arteriosclerosis and dementia. Moreover, researchers have found that the oldest of the old often enjoy better health than people in their 70s. The 79 centenarians in Perls’s New England study have all lived independently through their early 90s, taking an average of just one medication. And when the time comes for these hearty souls to die, they don’t linger. In a 1995 study, James Lubitz of the Health Care Financing Administration calculated that medical expenditures for the last two years of life–statistically the most expensive–average ">2,600 for people who die at 70, but just $8,300 for those who make it past 100.
These insights have spawned a revolution in the science of aging. “Until recently, there was so much preoccupation with disease that little work was done on the characteristics that permit people to do well,” says Dr. John Rowe, the New York geriatrician who heads the MacArthur Foundation’s Research Network on Successful Aging. Over the past decade, Rowe’s group and others have published hundreds of studies elucidating the factors that help people glide through their later years with clear minds and strong bodies. The research confirms the old saw that it pays to choose your parents well. But the way we age depends less on who we are than on how we live–what we eat, how much we exercise and how we employ our minds.
The Magic of Exercise
Suppose there was a potion that could keep you strong and trim as you aged, while protecting your heart and bones; improving your mood, sleep and memory; warding off breast and colon cancer, and reducing your overall risk of dying prematurely.
Respectable studies have shown that exercise can have all those benefits–even for people who take it up late in life. Experts now agree that most of the physical decline that older people suffer stems not from age but from simple disuse. When we sit all day, year after year, our bones, muscles and organ systems atrophy. But exercise can preserve and even revive them.
When Dr. Ralph Paffenbarger started tracking the health of 19,000 Harvard and University of Pennsylvania alumni back in the early 1960s, many experts thought vigorous exercise was downright dangerous for people over 50. But by monitoring the volunteers’ activity levels and health status over the years, the Stanford epidemiologist turned that wisdom on its head. In a landmark 1986 study, Paffenbarger showed that the participants’ death rates fell in direct proportion to the number of calories they burned each week. Those burning 2,000 a week (roughly the number it takes to walk 20 miles) suffered only half the annual mortality of the couch potatoes, thanks mainly to a lower rate of heart disease.
The alumni study wasn’t set up to gauge the benefits of any particular exercise regimen, but subsequent studies have shown that different activities bring different rewards. Everyone now agrees that aerobic exercise preserves the heart, lungs and brain. And researchers at Tufts University have recently shown that weight lifting can do as much for the frail elderly as it does for high-school jocks. When Dr. Maria Fiatarone got 10 chronically ill nursing-home residents to lift weights three times a week for two months, the participants’ average walking speed nearly tripled, and their balance improved by half. Two had the audacity to throw away their canes.
Miriam Nelson, another Tufts researcher, has since shown how a series of simple strength-training exercises could help keep women from resorting to canes in the first place. She recruited 40 volunteers–all past menopause, none taking estrogen–and split them into two groups. Half continued life as usual, while the other half went to Tufts twice a week to pump iron. Over the course of a year, the women in the control group suffered a predictable loss of bone density, but the weight lifters enjoyed slight increases. They didn’t lose weight (that wasn’t the goal), but they lost fat, and many ended up measurably stronger than their daughters, who were 30 to 40 years younger. Dorothy Barron, who was 64 when she joined Nelson’s experiment, says the experience not only remodeled her body but gave her more energy and confidence than she had had since her youth. Five years later, she still lifts weights–and she has added power walking, horseback riding and white-water rafting to her hobbies. When people ask why she pushes herself so hard, she replies, “I’m too old not to.”
Eating to Nourish Long Life
We all know that living on fat, salt and empty calories can have a range of nasty consequences, from obesity and impotence to hypertension and heart disease. Yet we seem to forget that there are other ways to eat, and that people who adopt them stay younger longer. George and Gaynel Couron will never forget that lesson. The Sacramento, Calif., couple gave up eating meat back in the early 1920s, when they became Seventh-day Adventists. They eventually strayed from the church and its dietary edicts, but they returned to both in 1943, when George suffered a heart attack. Today he’s 100 years old, and Gaynel is 98. They’ve been married for 81 years and have 14 kids ranging in age from 58 to 80. They have slowed down a bit (they’re not planning any more children), but George still takes great delight in growing and eating his own tomatoes, melons, beets, squash and black-eyed peas. As he puts it, “We’re still perking along.” No one can say exactly what role food has played in the Courons’ good fortune, but the age-reversing effects of a plant-based diet are not in question. In controlled studies, San Francisco cardiologist Dean Ornish has shown that a diet based on low-fat, nutrient-rich foods not only prevents heart disease–the Western world’s leading cause of early death–but can help reverse it. And other studies suggest that dietary changes could virtually eliminate the high blood pressure that places 50 million older Americans at high risk of stroke, heart attack and kidney failure.
“Hypertension is not an inevitable part of aging,” says Dr. Boyd Eaton, an Atlanta-based radiologist who has written extensively on nutrition and chronic illness. “It’s a disease of civilization.” You wouldn’t know that from watching people age in this country. Hypertension afflicts a third of all Americans in their 50s, half of those in their 60s and more than two thirds of those over 70. But preindustrial people don’t follow that pattern. Whether they happen to live in China or Africa, Alaska or the Amazon, people in primitive settings experience no change in blood pressure as they age, and the reason is fairly simple: they don’t eat processed foods. Dr. Paul Whelton of Tulane University’s School of Public Health has spent the past decade tracking 15,000 indigenous Yi people in southwestern China. As long as they eat a traditional diet–rice, a little meat and a lot of fresh fruits and vegetables–these rural farmers virtually never develop hypertension. But when they migrate to nearby towns, their blood pressure starts to rise with age. “Their genes don’t change when they move,” Whelton says. “Their diet does.”
What makes processed food so harmful? Salt is one key suspect. When you subsist mainly on fresh plant foods–as our ancestors did for roughly 7 million years–you get 10 times more potassium than sodium. That 10-to-one ratio is, by Eaton’s reasoning, the one our bodies are designed for. But salt is now showered on foods at every stage of processing and preparation (a 4-ounce tomato contains 9 mg of sodium, 4 ounces of bottled tomato sauce nearly 700 mg), while potassium leaches out. As a result, most of us now consume more salt than potassium. “Modern humans are the only mammals that do that,” says Eaton, “and we’re the only ones that develop hypertension.” Correcting that imbalance takes some effort, but it doesn’t require moving to the bush. In fact a recent clinical study suggests that dietary changes can reduce blood pressure as markedly as drug treatment, and can produce results in as little as two months. In the study (known as DASH, or Dietary Approaches to Stop Hypertension), researchers at several institutions placed volunteers on one of three diets. Those on a low-fat menu that included 10 daily servings of fresh fruits and vegetables, plus two servings of calcium-rich dairy products, reduced their systolic and diastolic readings by 5.5 mm and 3.0 mm, respectively. And those suffering from hypertension got reductions of twice that magnitude. “We suspected this was possible,” says nutritionist Eva Obarzanek of the National Heart, Lung and Blood Institute, the federal agency that sponsored the study. “Now we know the size of the effect.”
Researchers have since shown that a simple potassium supplement can bring similar if less dramatic benefits. That’s worth knowing, but keep in mind that potassium is just one of countless age fighters found in real food. The antioxidant vitamins in a tomato or a green leaf can help boost immunity and slow the corrosion of aging cell membranes, and the B vitamins may help protect your heart. By eating plants, you also bathe yourself in cancer-fighting phytochemicals, bone-saving calcium and the fiber needed to maintain the colon and modulate blood sugar. Best of all, you can down them by the bushel without getting fat.
If they do I'd like to find out about it. Send me their stories.
Selasa, 30 Juni 2009
Why do you reach a weight plateau. I'm still at 176 pounds
I'm on a plateau right now. I think I've been doing the right things on my program but I've stopped making progress. How can that be?
Almost everyone who diets to lose weight reaches a point where they stop losing weight for no apparent reason. They eat the same size portions, eat the right foods and do the same amount of exercise but they are stuck at the same weight.
Here's what's happening Our bodies have been losing right along and our body detects that we aren't getting the same quantities and same calories that it was formerly used to. A physical defense mechanism sets in and our body in effect tells all of its systems to conserve, to slow down, to be more efficient with the food it gets. It doesn't realize that we want to keep contracting or losing weight. It thinks we are making a mistake and physiologically it is going to correct this mistake. It tries to make one calorie act like two and thus keep us on this no lose plateau.
Don't worry. Don't fret and don't let your underwear bunch up on you. Your body will get used to your new lower weight and let you get on with your business of losing weight. Just "STAY the Course" and it will all work out. Naturally our watchword/slogan for this lesson is:
"STAY the COURSE".
Contact me at brownbagdiet@gmail.com or leave your comments below.
Almost everyone who diets to lose weight reaches a point where they stop losing weight for no apparent reason. They eat the same size portions, eat the right foods and do the same amount of exercise but they are stuck at the same weight.
Here's what's happening Our bodies have been losing right along and our body detects that we aren't getting the same quantities and same calories that it was formerly used to. A physical defense mechanism sets in and our body in effect tells all of its systems to conserve, to slow down, to be more efficient with the food it gets. It doesn't realize that we want to keep contracting or losing weight. It thinks we are making a mistake and physiologically it is going to correct this mistake. It tries to make one calorie act like two and thus keep us on this no lose plateau.
Don't worry. Don't fret and don't let your underwear bunch up on you. Your body will get used to your new lower weight and let you get on with your business of losing weight. Just "STAY the Course" and it will all work out. Naturally our watchword/slogan for this lesson is:
"STAY the COURSE".
Contact me at brownbagdiet@gmail.com or leave your comments below.
Kamis, 18 Juni 2009
The Association of Inhaled Corticosteroid Use with Serum Glucose Concentration in a Large Cohort
Abstract
Background
Inhaled corticosteroids (ICSs) are widely used in the treatment of obstructive lung disease. ICSs have been shown to be systemically absorbed. The association between ICS and serum glucose concentration is unknown.
Methods
To explore the association of ICS dosing with serum glucose concentration, we used a prospective cohort study of US veterans enrolled in 7 primary care clinics between December 1996 and May 2001 with 1 or more glucose measurements while at least 80% adherent to ICS dosing. The association between ICS dose from pharmacy records standardized to daily triamcinolone equivalents and serum glucose concentration was examined with generalized estimating equations controlling for confounders, including systemic corticosteroid use.
Results
Of the 1698 subjects who met inclusion criteria, 19% had self-reported diabetes. The mean daily dose of ICS in triamcinolone equivalents was 621 μg (standard deviation 555) and 610 μg (standard deviation 553) for subjects with and without diabetes, respectively. After controlling for systemic corticosteroid use and other potential confounders, no association between ICS and serum glucose was found for subjects without diabetes. However, among subjects with self-reported diabetes, every additional 100 μg of ICS dose was associated with an increased glucose concentration of 1.82 mg/dL (P value .007; 95% confidence interval [CI], 0.49-3.15). Subjects prescribed antiglycemic medications had an increase in serum glucose of 2.65 mg/dL (P value .003; 95% CI, 0.88-4.43) for every additional 100 μg ICS dose.
Conclusion
Among diabetic patients, ICS use is associated with an increased serum glucose concentration in a dose-response manner.
To read this article in its entirety, please visit our website.
Christopher G. Slatore, MD, Chris L. Bryson, MD, MS, David H. Au, MD, MS
This article was originally published in the May 2009 issue of The American Journal of Medicine.
Background
Inhaled corticosteroids (ICSs) are widely used in the treatment of obstructive lung disease. ICSs have been shown to be systemically absorbed. The association between ICS and serum glucose concentration is unknown.
Methods
To explore the association of ICS dosing with serum glucose concentration, we used a prospective cohort study of US veterans enrolled in 7 primary care clinics between December 1996 and May 2001 with 1 or more glucose measurements while at least 80% adherent to ICS dosing. The association between ICS dose from pharmacy records standardized to daily triamcinolone equivalents and serum glucose concentration was examined with generalized estimating equations controlling for confounders, including systemic corticosteroid use.
Results
Of the 1698 subjects who met inclusion criteria, 19% had self-reported diabetes. The mean daily dose of ICS in triamcinolone equivalents was 621 μg (standard deviation 555) and 610 μg (standard deviation 553) for subjects with and without diabetes, respectively. After controlling for systemic corticosteroid use and other potential confounders, no association between ICS and serum glucose was found for subjects without diabetes. However, among subjects with self-reported diabetes, every additional 100 μg of ICS dose was associated with an increased glucose concentration of 1.82 mg/dL (P value .007; 95% confidence interval [CI], 0.49-3.15). Subjects prescribed antiglycemic medications had an increase in serum glucose of 2.65 mg/dL (P value .003; 95% CI, 0.88-4.43) for every additional 100 μg ICS dose.
Conclusion
Among diabetic patients, ICS use is associated with an increased serum glucose concentration in a dose-response manner.
To read this article in its entirety, please visit our website.
Christopher G. Slatore, MD, Chris L. Bryson, MD, MS, David H. Au, MD, MS
This article was originally published in the May 2009 issue of The American Journal of Medicine.
Senin, 15 Juni 2009
Sorry for the absence of 2 months but I'm still on track
Sorry for the absence of 2 months but I'm still on track at 176 pounds.
Last time I reported I was at 178 pounds but since that time I had a little mishap. I thought hiking was a good way to get my exercise in and on a hiking trip I suffered a fall. The contusion on the long bone in my leg was severe but I didn't break anything or so they told me at the emergency room I visited. However the pain was getting worse and worse. So ten days later, after I returned home, I went to my Dr. who told me I had several fractures on one foot around my ankles. Fortunately everything remained in line and I avoided the need for surgery. However I spent the next two months in what they called an air boot. This is a device that acts somewhat like a cast but you can remove it to shower and when going to sleep. At any rate two months later my Dr. told me I had good bone formation and discharged me.
What has all this to do with weight loss? Simply put, life is complicated. Although I expected a smooth program for weight reduction this complication got in the way of my concentrating on my task to lose weight. However in the preceding weeks on my diet program I developed pretty good eating habits. During the entire time in which I had the air boot I never once got on the scale. I didn't try to follow my diet but to my surprise during the preceding weeks I had already developed some pretty good eating habits and those good habits paid off.
Although two months passed before I got on the scale again I was surprised to find that I hadn't gained weight. And I'm on the downtrend again with another two pound weight loss.
So what does this prove? It's simple. Good things happen when you develop good habits and bad things continue to happen when you never start or never try to go on a sensible weight loss program. I suppose we could adopt a new watchword/slogan that expresses this idea. That is Good things happen when you try - so keep trying.
You can contact me at brownbagdiet@gmail.com or post you comment on this blog.
Good luck.
Last time I reported I was at 178 pounds but since that time I had a little mishap. I thought hiking was a good way to get my exercise in and on a hiking trip I suffered a fall. The contusion on the long bone in my leg was severe but I didn't break anything or so they told me at the emergency room I visited. However the pain was getting worse and worse. So ten days later, after I returned home, I went to my Dr. who told me I had several fractures on one foot around my ankles. Fortunately everything remained in line and I avoided the need for surgery. However I spent the next two months in what they called an air boot. This is a device that acts somewhat like a cast but you can remove it to shower and when going to sleep. At any rate two months later my Dr. told me I had good bone formation and discharged me.
What has all this to do with weight loss? Simply put, life is complicated. Although I expected a smooth program for weight reduction this complication got in the way of my concentrating on my task to lose weight. However in the preceding weeks on my diet program I developed pretty good eating habits. During the entire time in which I had the air boot I never once got on the scale. I didn't try to follow my diet but to my surprise during the preceding weeks I had already developed some pretty good eating habits and those good habits paid off.
Although two months passed before I got on the scale again I was surprised to find that I hadn't gained weight. And I'm on the downtrend again with another two pound weight loss.
So what does this prove? It's simple. Good things happen when you develop good habits and bad things continue to happen when you never start or never try to go on a sensible weight loss program. I suppose we could adopt a new watchword/slogan that expresses this idea. That is Good things happen when you try - so keep trying.
You can contact me at brownbagdiet@gmail.com or post you comment on this blog.
Good luck.
Kamis, 04 Juni 2009
Adherence to Healthy Lifestyle Habits in US Adults, 1988-2006
Lifestyle choices are associated with cardiovascular disease and mortality. Comparing healthy lifestyle habits in adults between 1988 and 2006, the authors found adherence to 5 healthy habits decreased from 15% to 8% in the US, as obesity increased.
Abstract
Background
Lifestyle choices are associated with cardiovascular disease and mortality. The purpose of this study was to compare adherence to healthy lifestyle habits in adults between 1988 and 2006.
Methods
Analysis of adherence to 5 healthy lifestyle trends (≥5 fruits and vegetables/day, regular exercise >12 times/month, maintaining healthy weight [body mass index 18.5-29.9 kg/m2], moderate alcohol consumption [up to 1 drink/day for women, 2/day for men] and not smoking) in the National Health and Nutrition Examination Survey 1988-1994 were compared with results from the National Health and Nutrition Examination Survey 2001-2006 among adults aged 40-74 years.
Results
Over the last 18 years, the percent of adults aged 40-74 years with a body mass index ≥30 kg/m2 has increased from 28% to 36% (P <.05); physical activity 12 times a month or more has decreased from 53% to 43% (P <.05); smoking rates have not changed (26.9% to 26.1%); eating 5 or more fruits and vegetables a day has decreased from 42% to 26% (P <.05), and moderate alcohol use has increased from 40% to 51% (P <.05). Adherence to all 5 healthy habits has gone from 15% to 8% (P <.05). Although adherence to a healthy lifestyle was lower among minorities, adherence decreased more among non-Hispanic Whites over the period. Individuals with a history of hypertension/diabetes/cardiovascular disease were no more likely to be adherent to a healthy lifestyle than people without these conditions.
Conclusions
Generally, adherence to a healthy lifestyle pattern has decreased during the last 18 years, with decreases documented in 3 of 5 healthy lifestyle habits. These findings have broad implications for the future risk of cardiovascular disease in adults.
To read this article in its entirety, please visit our website.
-- Dana E. King, MD, MS, Arch G. Mainous III, PhD, Mark Carnemolla, BS, Charles J. Everett, PhD
This article was originally published in the June 2009 issue of The American Journal of Medicine.
Abstract
Background
Lifestyle choices are associated with cardiovascular disease and mortality. The purpose of this study was to compare adherence to healthy lifestyle habits in adults between 1988 and 2006.
Methods
Analysis of adherence to 5 healthy lifestyle trends (≥5 fruits and vegetables/day, regular exercise >12 times/month, maintaining healthy weight [body mass index 18.5-29.9 kg/m2], moderate alcohol consumption [up to 1 drink/day for women, 2/day for men] and not smoking) in the National Health and Nutrition Examination Survey 1988-1994 were compared with results from the National Health and Nutrition Examination Survey 2001-2006 among adults aged 40-74 years.
Results
Over the last 18 years, the percent of adults aged 40-74 years with a body mass index ≥30 kg/m2 has increased from 28% to 36% (P <.05); physical activity 12 times a month or more has decreased from 53% to 43% (P <.05); smoking rates have not changed (26.9% to 26.1%); eating 5 or more fruits and vegetables a day has decreased from 42% to 26% (P <.05), and moderate alcohol use has increased from 40% to 51% (P <.05). Adherence to all 5 healthy habits has gone from 15% to 8% (P <.05). Although adherence to a healthy lifestyle was lower among minorities, adherence decreased more among non-Hispanic Whites over the period. Individuals with a history of hypertension/diabetes/cardiovascular disease were no more likely to be adherent to a healthy lifestyle than people without these conditions.
Conclusions
Generally, adherence to a healthy lifestyle pattern has decreased during the last 18 years, with decreases documented in 3 of 5 healthy lifestyle habits. These findings have broad implications for the future risk of cardiovascular disease in adults.
To read this article in its entirety, please visit our website.
-- Dana E. King, MD, MS, Arch G. Mainous III, PhD, Mark Carnemolla, BS, Charles J. Everett, PhD
This article was originally published in the June 2009 issue of The American Journal of Medicine.
Failing Grades in the Adoption of Healthy Lifestyle Choices
Heart disease is the leading cause of death for both men and women in the United States. During 2002, nearly 700,000 individuals in the US died of heart disease.(1) Of these deaths, approximately 500,000 are the result of ischemic coronary heart disease, with 47% of these individuals dying before emergency services or transport to a hospital could occur. Fifty-one percent of those dying of heart disease are women.(2, 3) Heart disease is the leading cause of death for most American ethnic groups, including whites, African Americans, Hispanics, American Indians, and Alaskan Natives. Discouragingly, heart disease death rates are 30% higher in African Americans compared with whites.(2) The projected cost for the immense burden of heart disease in the US during 2006 was between $143 and $258 billion, including health care services, medications, and lost productivity.(4, 5)
Risk factors for the development of atherosclerotic disease are unfortunately widespread in the US population. Indeed, between 1999 and 2000, approximately 30% of individuals aged 20 years or older had diagnosed hypertension or were taking antihypertensive medication, 17% had high blood cholesterol, 6.5% were diabetic, 30.5% were obese, and more than 21% smoked cigarettes. Moreover, more than 37% reported no leisure-time physical activity.(2) In 2003, approximately 37% of American adults reported having 2 or more of these risk factors for cardiovascular disease. Ninety percent of patients with ischemic coronary artery disease have at least one atherosclerotic risk factor.(6)
With these grim statistics in mind, the report of King et al in this issue of The American Journal of Medicine is very disturbing.(7) Despite vigorous efforts on the part of national and local health authorities and organizations such as the American Heart Association, the incidence of atherosclerotic arterial disease risk factors has actually increased in recent years. King et al compared 5 major atherosclerotic risk factors…
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD
Editor-in-Chief, The American Journal of Medicine
This article was originally published in the June 2009 issue of The American Journal of Medicine.
Risk factors for the development of atherosclerotic disease are unfortunately widespread in the US population. Indeed, between 1999 and 2000, approximately 30% of individuals aged 20 years or older had diagnosed hypertension or were taking antihypertensive medication, 17% had high blood cholesterol, 6.5% were diabetic, 30.5% were obese, and more than 21% smoked cigarettes. Moreover, more than 37% reported no leisure-time physical activity.(2) In 2003, approximately 37% of American adults reported having 2 or more of these risk factors for cardiovascular disease. Ninety percent of patients with ischemic coronary artery disease have at least one atherosclerotic risk factor.(6)
With these grim statistics in mind, the report of King et al in this issue of The American Journal of Medicine is very disturbing.(7) Despite vigorous efforts on the part of national and local health authorities and organizations such as the American Heart Association, the incidence of atherosclerotic arterial disease risk factors has actually increased in recent years. King et al compared 5 major atherosclerotic risk factors…
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD
Editor-in-Chief, The American Journal of Medicine
This article was originally published in the June 2009 issue of The American Journal of Medicine.
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