tag:blogger.com,1999:blog-3401765768881205082024-03-17T23:03:25.445-07:00Dr Colin KopesKerr Evidence for Lifestyle & HealthDr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.comBlogger52125tag:blogger.com,1999:blog-340176576888120508.post-3857976208924122492013-06-26T10:47:00.001-07:002013-06-26T10:47:24.357-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: Trebuchet MS, sans-serif;"><b>A VIEW FROM THE OFFICE</b></span></div>
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<span style="font-family: Trebuchet MS, sans-serif;"><b>MEDICINE'S DIRTY LITTLE SECRET</b></span></div>
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<strong><span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">HYPERTENSION DOESN'T NEED TO BE
TREATED (A LOT OF IT ANYWAY): </span></strong><span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">In
1990 I reviewed all of the then available studies on the treatment of mild to
moderate hypertension and was more than mildly surprised by the following
observations:</span><o:p></o:p></div>
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<li class="MsoNormal"><span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">The trials showed a significant benefit in reducing
both fatal and nonfatal stroke (40-44% reductions).</span><o:p></o:p></li>
<li class="MsoNormal"><span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">The benefit for stroke reduction in middle-aged
patients could be observed after only 4-6 weeks of treatment.</span><o:p></o:p></li>
<li class="MsoNormal"><span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">No statistically significant benefit in the reduction
of fatal or nonfatal MI was observed.</span><o:p></o:p></li>
<li class="MsoNormal"><span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">There appeared to be no value in treating isolated mild
to moderate hypertension in younger adults in the absence of risk factors.</span><o:p></o:p></li>
<li class="MsoNormal"><span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">Treatment of mild to moderate hypertension was not
cost-effective.</span><o:p></o:p></li>
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<span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">(I published the results of my
review in <em>J Am Board
FP</em> in 1993 </span><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; font-family: Arial, sans-serif; font-size: 8.5pt;"> <span style="background-position: initial initial; background-repeat: initial initial; font-family: 'Trebuchet MS', sans-serif;">May-Jun;6(3):243-54</span></span><span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">.)
(1)</span><o:p></o:p></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">This led me to the conclusion that <strong><span style="color: #0a0fab;">pharmacological
management of mild-to-moderate hypertension should be directed only at
those with elevated cardiac risk profiles</span></strong>. This, of course,
meant that <strong><span style="color: #bf0b2f;">you would actually have to perform a cardiac risk assessment to
determine global cardiac risk</span></strong>. Otherwise lifestyle measures</span> <span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">are
all that is needed for everyone else. My subsequent research into the effects
of healthy lifestyles also supported this conclusion.(2)</span><o:p></o:p></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">I have been alone in this opinion
for most of my career, but now at last the Cochrane Collaboration has published
a definite confirmation of this approach.(3)</span> <span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">Their conclusions are likely to
surprise you. The authors reviewed 11 RCTs and based their conclusions on only
4 qualified studies. These studies included 8,912 subjects who were treated for
4 to 5 years with antihypertensive drugs as compared to placebo. <strong><span style="color: #0a0fab;">Active treatment
with medication did not reduce total mortality. In 7,080 participants treated
with antihypertensive drugs as compared to placebo did not reduce coronary
heart disease, stroke, or total cardiovascular events</span></strong>. </span><o:p></o:p></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">A follow-up editorial in JAMA
explains how we came to be managing hypertension all wrong for over 20
years.(4)</span> <span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">The
author begins with a quotation from Julian Tudor Hart, the pioneer of screening
for hypertension at <strong><span style="color: #0a0fab;">the previous threshold of 160/100 mm Hg</span></strong>: "<strong><span style="color: #bf0b2f;">Why has it taken
more than 30 years to reach this conclusion, when it was already evident from
any careful and critical reading of the trials claimed originally to justify
interventions in the diastolic range 90-100 mm Hg?</span></strong>"</span><o:p></o:p></div>
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<strong><span style="color: #0a0fab; font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">The effect of changing
the disease definition was to create 13 million new hypertensive patients in
the US</span></strong><span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">. In that same year, more than 800
physicians, pharmacists, and scientists from 42 countries signed an open letter
to the Director-General of the WHO complaining that these new guidelines 'would
result in increased use of antihypertensive drugs, at great expense and for
little benefit.'</span>
<span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">The editorial goes on to observe:</span><o:p></o:p></div>
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"The following year, Getz and colleagues described the results of applying
these European guidelines to the entire population of a county in Norway. The
Nord-Trondelag Health Study provides BP and serum cholesterol level data for
some 62,000 adults aged between 20 and 79 years in the period 1995 through
1997. <u>When the European guidelines are applied, half the population are
considered to be at risk by the early age of 24 years. By the age of 49 years,
this proportion increases to 90%, and as much as 76% of the total adult
population are found to be at 'increased risk.</u>' <strong><span style="color: #0a0fab;">Yet the current life expectancy at birth in Norway is 79
years for men and 83 years for women, making it one of the longest-living
populations in history</span></strong>. In this context, the thresholds cannot
be appropriate, and it is perhaps important to note that <strong><span style="color: #bf0b2f;">every one of the numerous authors of the European
guidelines reported some degree of support from the pharmaceutical industry</span></strong>.<o:p></o:p></div>
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"In 204, the Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) sponsored by
the US National Heart, Lung, and Blood Institute pushed the thresholds even
lower, stating the prehypertensive individuals (systolic BP, 120-139 mm Hg, or
diastolic BP, 80-89 mm Hg) require health-promoting lifestyle modifications to
prevent the progressive rise in BP and cardiovascular disease. <strong><span style="color: #bf0b2f;">Nine of 10 members of the Executive Committee responsible
for JNC7 record conflicts of interest relating to the receipt of payments from
the pharmaceutical industry</span></strong>."<o:p></o:p></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">It was after the publication of JNC
7 that I first began to suspect that the drug companies were deliberately
leading us astray. I wrote extensively on my disagreements with JNC 7 in <em>The Action Advisor for Primary
Care</em>, "<b><i>You Should Read the JNC 7 Guidelines on Hypertension and
Then Freely Deviate from Them As You Feel Appropriate for Your
Practices</i></b>".(5)</span><o:p></o:p></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">The primary article above cites the guidance from
the national Institute for Health and Care Excellence; according to this
guideline <strong><span style="color: #0a0fab;">drug treatment for hypertension should be offered to people aged
younger than 80 years with stage 1 hypertension (BP < 160/100) <u>only </u>if they
also have target organ damage, established cardiovascular disease, renal
disease, diabetes, and/or a 10-year cardiovascular risk equivalent to 20% or
greater</span></strong>. Dr. Heath concludes: "<b><u>In view of the mounting
evidence of both waste and harm, it is well time that we returned to the higher
threshold of 160/100 mg Hg for the pharmaceutical treatment of hypertension in
otherwise healthy people.</u></b> The Eighth Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
provides a timely opportunity for achieving this, but, with the probably degree
of industry entanglement, it seems a remote possibility. <strong><span style="color: #bf0b2f;">However, sooner
or later the pharmaceutical treatment of mild hypertension seems likely to be
consigned to what the novelist Amitav Ghosh has described as 'medicine's vast
graveyard of discredited speculations</span></strong>.'"</span><o:p></o:p></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; mso-fareast-font-family: "Times New Roman";">COMMENT: Isn't the practice of
medicine rather a marvel!? Just don't say I didn't tell you so.</span><o:p></o:p></div>
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Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com8tag:blogger.com,1999:blog-340176576888120508.post-17026632972832469812013-04-22T16:22:00.001-07:002013-04-22T16:22:22.634-07:00EATING HEALTHY: THE CALCIUM QUANDARY<div style="text-align: center;"><span style="font-family: Trebuchet MS, sans-serif;"><b>A VIEW FROM THE OFFICE</b></span></div><div style="text-align: center;"><span style="font-family: Trebuchet MS, sans-serif;"><b><br />
</b></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpVUPLAJAFAYHiq6900qe07eOGlAHFw5TdS_eFA-PEkIGBL9m_yDNHElrgzy7q2fIOGwe9FucWJiPBYEvuEEZBMmTenCIU2Hv_dZ3LBNQ5R9u5r2isi-oEjK6JO2MA4Z9V010VBtzNjJ4/s1600/Viewfromoffice2.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpVUPLAJAFAYHiq6900qe07eOGlAHFw5TdS_eFA-PEkIGBL9m_yDNHElrgzy7q2fIOGwe9FucWJiPBYEvuEEZBMmTenCIU2Hv_dZ3LBNQ5R9u5r2isi-oEjK6JO2MA4Z9V010VBtzNjJ4/s320/Viewfromoffice2.JPG" width="320" /></a></div><div style="text-align: center;"><span style="font-family: Trebuchet MS, sans-serif;"><b><br />
</b></span></div><div style="text-align: center;"><span style="font-family: Trebuchet MS, sans-serif;"><b>EATING HEALTHY: MORE ON THE CALCIUM QUANDARY</b></span></div><div style="text-align: center;"><span style="font-family: Trebuchet MS, sans-serif;"><b><br />
</b></span></div><div style="text-align: left;"></div><div align="center" class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: Trebuchet MS;"><strong>MORE ON CALCIUM AND OTHER STUFF</strong></span></div><div align="center" class="MsoNormal" style="margin: 0in 0in 0pt;"><br />
</div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><u><span style="color: #0f0780;"><strong><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;"><span style="background-color: white; font-weight: normal;"></span></span></span></strong></span></u><span style="font-family: trebuchet ms,helvetica,sans-serif;"><u><span style="color: #0f0780;"><strong>SOME MORE DATA ON CALCIUM AND HEART DISEASE</strong></span></u>: </span><span style="font-family: trebuchet ms,helvetica,sans-serif;">In a recent issue I wept over the US Preventive Services Task recent statement on routine calcium and vitamin D supplementation. They went on record as against it. My assertion is that they were woefully premature as conclusive data just aren't there yet. This question from a subscriber is an example of the kind of agony they have caused for primary care doctors</span>:</div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;"><span style="background-color: white; color: #500050;"></span></span></span><br />
</div><div class="MsoNormal" style="margin: 0in 0in 0pt 40px;"> <span style="font-family: times new roman,times,serif;"> </span><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;"><span style="font-family: times new roman,times,serif;"><span style="background-color: white; color: #500050;">My name is Bob and I'm a Vit D prescriber. I feel powerless in the face of</span><br style="background-color: white; color: #500050; font-family: arial, sans-serif; font-size: 13px;" /><span style="background-color: white; color: #500050;">the USPFTF's recommendations. I enjoyed your wry comments. But what about</span><br style="background-color: white; color: #500050; font-family: arial, sans-serif; font-size: 13px;" /><span style="background-color: white; color: #500050;">those concerns about increased heart disease from Ca supplementation?</span><br style="background-color: white; color: #500050; font-family: arial, sans-serif; font-size: 13px;" /><span style="background-color: white; color: #500050;">That's what I worry about.</span></span></span></span></div><div class="MsoNormal" style="margin: 0in 0in 0pt 40px;"><br />
</div><div class="MsoNormal" style="margin-bottom: 0pt; margin-right: 0in; margin-top: 0in;"><span style="font-family: trebuchet ms,helvetica,sans-serif;">Here's my response:</span><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;"><br />
</span></span></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;"><span style="background-color: white; color: #500050;"></span><br />
</span></span></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;"><span style="background-color: white; color: #222222;"> </span></span></span> <span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;"><span style="background-color: white; color: #222222;">"You ask a good question about calcium supplementation, and I have concerns as well. In making a decision in cases like this I revert back to a basic set of principles of medical evidence.</span></span></span><div style="background-color: white; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;"><br />
</span></span></div><div style="background-color: white; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;">1. <strong><span style="color: #0f0780;">Never change practice based on 1 study or just 1 evidence review.</span></strong> I reviewed the USPSTF statement, and it poses as many questions as they had answers (mostly wrong, in my opinion). The USPSTF clearly acknowledges that we need more data. I don't understand why they changed such a common, appropriate practice overnight. I just don't think the data are there yet. But the issue has been raised, and I will continue to search for more data.</span></span> [See below.]</div><div style="background-color: white; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;"><br />
</span></span></div><div style="background-color: white; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;">2. Whenever we've been doing something for 50 years or so with no reason to be concerned about,<span style="color: #0f0780;"><strong> I fundamentally mistrust the new study that says STOP doing it</strong></span>. The methodologies of all these studies vary greatly, their level of significance varies, and they are not really homogeneous, so it is difficult to put them into meta-analyses. </span></span></div><div style="background-color: white; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;"><br />
</span></span></div><div style="background-color: white; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;">3. <span style="color: #0f0780;"><strong>Look at the big picture</strong></span>. During this same time (last 50 years), cardiovascular disease has clearly and markedly declined (despite all the calcium we were recommending). I have not seen any one of my patients die of calcium-induced heart disease. (How would I know?) The recommendation seeks to have us remove a reputed agent of heart disease that we cannot see at work. This can lead to a lot of superstitious medicine. If I am going to be superstitious, it is going to be in the direction of encouraging nutritional adequacy across the board.</span></span></div><div style="background-color: white; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;"><br />
</span></span></div><div style="background-color: white; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;">4. <span style="color: #0f0780;"><strong>Apply common sense</strong></span>: We know that the diets that most Americans eat these days are highly flawed. Significant rates of deficiency have been shown for vitamin C, D, folate, B12, and iron. It is absolutely counter-intuitive not to tell patients to get the recommended minimum amounts of calcium and vitamin D. Calcium is a much studied nutrient. We have studies showing the supplementation leads to reduced rates of obesity, colon cancer, and osteoporosis. How come the adverse cardiovascular effect never showed up in those studies? What is to say that the new studies are better and more definitive than the older studies. My expectation is that newer studies will show the USPSTF position irrelevant. [One example appears below.]</span></span></div><div style="background-color: white; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;"><br />
</span></span></div><div style="background-color: white; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;">Finally, what I dislike most about this USPSTF recommendation is that <strong><span style="color: #0f0780;">it just so flies in the face of primary care physicians who have made a concerted effort to do the right thing</span></strong>, as it was previously recommended. When they come out with a new, different recommendation, the data need to be definitive. The worst thing they could do is to leave us in a no-man's land, which is what they have done. When we in primary care feel this upset about an issue, sometimes we're right.</span></span></div><div style="background-color: white; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;"><br />
</span></span></div><div style="background-color: white; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;">Let's wait and see how the data unfold. In the meantime keep prescribing the minimum RDA of calcium and vitamin D."</span></span></div><div style="background-color: white; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;"></span></span><br />
</div><div style="background-color: white; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;">The saga will continue. </span></span></div><div style="background-color: white; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;"></span></span><br />
</div><div style="background-color: white; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><span style="font-size: 16px;"><span style="font-family: trebuchet ms,helvetica,sans-serif;"><span style="color: #0f0780;"><strong><u>IT DIDN'T TAKE LONG: "DIETARY AND SUPPLEMENTAL CALCIUM INTAKE AND CARDIOVASCULAR DISEASE MORTALITY: THE NATIONAL INSTITUTES OF HEALTH--AARP DIET AND HEALTH STUDY":</u></strong> </span>This was a prospective study from 1995 through 1996 in California, Florida, Louisiana, New Jersey, North Carolina, and Pennsylvania and the two metropolitan areas of Atlanta, Georgia, and Detroit, Michigan.(1) There were a total of 388,229 men and women aged 50 to 71 years included in the study. Dietary and supplemental calcium intake was assessed at baseline. Supplemental calcium intake included calcium from multivitamins and individual calcium supplements. During a mean of 12 years of follow-up, 7904 and 3874 cardiovascular deaths occurred in men and women, respectively. Supplements containing calcium were used by 51% of men and 70% of women. In men, supplemental calcium intake was associated with an elevated risk of CVD death (RR 1.20), more specifically with heart disease death (RR, 1.19), but not significantly with cerebrovascular disease death (RR, 1.14). In women, supplemental calcium intake was not associated with CVD death (RR, 1.06), heat disease death (1.05), or cerebrovascular disease death (1.08). <strong><span style="color: #0f0780;">Dietary calcium intake was unrelated to CVD death in either men or women</span></strong>. The authors conclude simply that more studies are needed. COMMENT: So what is all the fuss about? Most of the supplements we prescribe are to older women who do not appeared to be harmed at all by this. </span></span></div></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: trebuchet ms,helvetica,sans-serif;"><span style="color: #0f0780;"><strong><u>AND, YES, VIRGINIA, COUNSELING ABOUT DIET IS GOOD FOR REDUCING CARDIOVASCULAR RISK</u>:</strong></span> Notwithstanding the misguided opinion of the USPSTF, the Cochrane Collaboration does indeed find dietary counseling to be a good thing.(2)</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">These Cochrane collaborators analyzed randomized studies with no more than 20% loss to follow-up, which lasted at least 3 months, and involved healthy adults comparing dietary advice with no advice or minimal advice. Trials involving children, trials to reduce weight, and trials involving supplementation were excluded. The investigators found 42 trials with 52 intervention arms (comparisons) comparing dietary advice with no advice. There were 18,175 participants or clusters randomized. 29 of the 44 included trials were conducted in the US. <strong><span style="color: #078039;">Dietary advice reduced total serum cholesterol by 0.15 mmol/L and LDL cholesterol by 0.16 mmol/L after 3 to 24 months</span></strong>. Mean HDL cholesterol levels and triglyceride levels were unchanged. <span style="color: #078039;"><strong>Dietary advice reduced blood pressure by 2.61 mm Hg systolic and 1.45 mm Hg diastolic and 24-hour urinary sodium excretion by 40.9 mmol after 3 to 36 months.</strong></span> Compared to no advice, <strong><span style="color: #078039;">dietary advice increased fruit and vegetable intake by 1.18 servings a day</span></strong>. <strong><span style="color: #078039;">Dietary fiber intake increased with advice by 6.5 g/day</span></strong>, while <strong><span style="color: #078039;">total dietary fat as a percentage of total energy intake fell by 4.48% with dietary advice</span></strong>, and <strong><span style="color: #078039;">saturated fat intake fell by 2.39%</span></strong>. The authors conclude: "Dietary advice appears to be effective in bringing about modest beneficial changes in diet and cardiovascular risk factors over approximately 12 months, but longer-term effects are not known." COMMENT: It should be no discouragement that the benefits are in relatively small percentages because we are talking about brief, simple interventions across the entire population. Just as every 1-2 mm Hg and 1-2 mg of cholesterol make a difference, so does every extra serving of fruits and vegetables. The goal is only 5. We can get there. It will make a difference!</span></div><br />
<br />
References:<br />
<br />
Xiao Q et al. Dietary and supplemental calcium intake and cardiovascular disease mortality: The National Institutes of Health-AARP Diet and Health Study. JAMA Intern Med 2013; 173(8): 639-46.<br />
<br />
Rees K et al. Dietary advice for reducing cardiovascular risk. Cochrane Database Syst Rev. 2013 Mar 28:3: CD002128. doi: 10.1002/14651858. CD002128.pub4. PMID: 23543514.<br />
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Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com6tag:blogger.com,1999:blog-340176576888120508.post-64995040654233759072013-04-04T16:56:00.003-07:002013-04-04T16:56:36.845-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: Trebuchet MS, sans-serif;"><b>A VIEW FROM THE OFFICE</b></span></div>
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<span style="font-family: Trebuchet MS, sans-serif;"><b><br /></b></span></div>
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<span style="font-family: Trebuchet MS, sans-serif;"><b><br /></b></span></div>
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<span style="font-family: Trebuchet MS;"><strong>THE COMPLETE 'CHOOSING WISELY' GUIDELINES</strong></span></div>
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<span style="font-family: Trebuchet MS;"><strong>THE BEST WHAT-NOT-TO-DO's IN MEDICINE: </strong>We
are at the threshold of a new era in medicine that really began with an
article in Annals of Internal Medicine(1), which I reviewed in the Jan
12th issue of the Journal of the FP Revolution in 2012.</span> <span style="font-family: 'trebuchet ms', helvetica, sans-serif;">This
started a brand new movement in medicine which has now gained
substantial momentum. A large number of generalist and specialist
societies have now identified and endorse a core set of test,
evaluations</span><span style="font-family: 'trebuchet ms', helvetica, sans-serif;">,
and practices that no longer ought to be done. [Actually we should
never have been doing them, but we're slow learners making progress.]
Since they are posted in the Internet in obscure locations (2), many of
us have never seen them. Therefore, I am going to just provide a graphic
to illustrate each of them with no other commentary in this issue. Read
'em and learn 'em. They're great!</span></div>
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<span style="font-family: 'trebuchet ms', helvetica, sans-serif;">Here's the main point:<span style="color: blue;"><b> There is almost universal consensus among medical experts (including myself) that the medical procedures listed below</b></span> <span style="color: red;"><b>SHOULD NOT BE DONE</b></span>. If your doctor is recommending any of them, ask him/her, "<b>Why?</b>" Or, equally acceptable, <span style="color: blue;"><b>just say NO!</b></span></span></div>
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<span style="font-family: 'trebuchet ms', helvetica, sans-serif;"><span style="color: blue;"><b><br /></b></span></span></div>
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<span style="font-family: 'trebuchet ms', helvetica, sans-serif;"><b style="color: blue;"> </b>Also very valuable for consumers are the consumer information sheets that accompany each one of these guidelines. There is a sample at the bottom of this page. The whole set can be found at this link: </span><span style="font-family: Trebuchet MS;"> </span><span style="font-family: arial, helvetica, sans-serif;"><a href="http://click.icptrack.com/icp/relay.php?r=&msgid=31524789&act=11111&c=68461&destination=http%3A%2F%2Fwww.choosingwisely.org%2Fdoctor-patient-lists%2F" target="_blank">http://www.choosingwisely.org/doctor-patient-lists/</a></span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">My favorites are (a Baker's Dozen):</span></div>
<ol>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"><strong>No routine pre-operative lab tests in average risk patients</strong>:
not chest x-rays, ECGs, or chemistries or coagulation tests. Let's face
it. Hospitals and surgicenters want these only for revenue production.</span></li>
<li class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="font-family: trebuchet ms,helvetica,sans-serif;">No DEXA scanning for bone mineral density until age 65 in women, one-time only, and age 70 in men.</span></li>
<li class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="font-family: trebuchet ms,helvetica,sans-serif;">No
routine annual cholesterol panel in patients <u>not</u> on a special diet or drug
therapy. [Note: This puts us at odds with many so-called expert
guidelines that govern organizations like Kaiser, Community Health
Centers, etc. Once every 5 years is enough for people without risk
factors or disease.]</span></li>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">Don't perform Pap smears on women younger than 21.</span></li>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">Don't order HPV (human papilloma virus) testing on women younger than 30.</span></li>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">Don't
order carotid ultrasounds as screening for asymptomatic patients. [The
corollary of this is, Don't auscultate for bruits (a harsh sound from irregular blood flow) on routine exams. A
finding of a bruit will make your doctor really, really want to order an
ultrasound. Don't let him/her! The USPSTF specifically <span style="color: red;"><b>'recommends against</b></span>' it
because known harms exceed known benefits.</span></li>
<li class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="font-family: trebuchet ms,helvetica,sans-serif;">Don't
repeat colon cancer screening by any method (including stool blood testing) for 10
years after a negative colonoscopy in average-risk individuals.</span></li>
<li class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="font-family: trebuchet ms,helvetica,sans-serif;">In the hospital don't order daily blood counts and chemistry panels in the face of clinical and lab stability.</span></li>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">No echocardiograms or carotid ultrasounds for patients with simple syncope (faint).</span></li>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">Don't order nuclear thyroid scans to evaluate thyroid nodules if thyroid function is normal.</span></li>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">Don't prescribe cough and cold medications for children <u><</u> 4 years of age. [Their parents can always do this, but physicians shouldn't be doing it.]</span></li>
<li class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="font-family: trebuchet ms,helvetica,sans-serif;">Don't perform ultrasound testing for boys with undescended testicles. [This is a new one for me.]</span></li>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">Don't
order special testing for clotting disorders when patient presents with
a first episode of a venous leg clot with a known cause (such as a recent fall, fracture, surgery, or other trauma). Don't re-image a venous leg clot in the
absence of a clinical change.</span></li>
</ol>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">Go ahead and pick your own favorites from the lists below. [...and let your friends know!]</span><br />
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<span style="font-family: Trebuchet MS;"><strong> </strong></span></div>
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<span style="font-family: Trebuchet MS;"><strong><img height="737" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/3d50231a5b892f45afdbddca577ce50d/image/jpeg" width="570" /> </strong></span></div>
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<span style="font-family: Trebuchet MS;"><strong><img height="738" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/2969bfc02d4bd00b9636d6779fa4d53b/image/jpeg" width="571" /> </strong></span></div>
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<span style="font-family: Trebuchet MS;"><strong> </strong></span></div>
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<span style="font-family: Trebuchet MS;"><strong> <img height="755" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/fabca0e9253f750f900d5e691291ab3f/image/jpeg" width="585" /></strong></span></div>
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<img height="745" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/efeabbcb85deeb857ce39efeed64956b/image/jpeg" width="577" /></div>
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<img height="742" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/22361c9b6bdf94ca7496a53803b8c5e1/image/jpeg" width="574" /></div>
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<img height="733" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/e4d25b76376eb9a128ab0abdb9f8cda1/image/jpeg" width="567" /></div>
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<img height="742" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/45d7998ec59c39ad147c0b942d2a6055/image/jpeg" width="572" /></div>
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<img height="736" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/82e246b11e983b40a64e27ab22731269/image/jpeg" width="570" /></div>
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<span style="font-family: Trebuchet MS;"> </span></div>
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<img align="" alt="" height="720" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/19fa2dbf8e2720cb6180c4d8990a0eff/image/jpeg" style="border: 0px solid rgb(0, 0, 0); margin: 0px;" width="557" /></div>
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<img align="" alt="" height="746" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/e9c6a9e8484e04ccc925eb2806ee8ad3/image/jpeg" style="border: 0px solid rgb(0, 0, 0); margin: 0px;" width="577" /></div>
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<img align="" alt="" height="748" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/f36fc998fe1cda1d325aec2d9f83c021/image/jpeg" style="border: 0px solid rgb(0, 0, 0); margin: 0px;" width="579" /></div>
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<img align="" alt="" height="746" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/4d4180affef07dee3c7a2cc39544870d/image/jpeg" style="border: 0px solid rgb(0, 0, 0); margin: 0px;" width="577" /></div>
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<img align="" alt="" height="750" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/cc671f9b0263eb67dd006d186fc17b93/image/jpeg" style="border: 0px solid rgb(0, 0, 0); margin: 0px;" width="580" /></div>
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<img align="" alt="" height="735" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/f98d4d36967c93b799648f851a087085/image/jpeg" style="border: 0px solid rgb(0, 0, 0); margin: 0px;" width="567" /></div>
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<img align="" alt="" height="771" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/e1c5e69d4121f2dfa939ad0375b68a17/image/jpeg" style="border: 0px solid rgb(0, 0, 0); margin: 0px;" width="596" /></div>
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<img align="" alt="" height="740" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/91d5ead3c7a41dfd7d8d5a5ea9fefd2b/image/jpeg" style="border: 0px solid rgb(0, 0, 0); margin: 0px;" width="572" /></div>
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<img align="" alt="" height="740" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/77d61198c4d3e446a1f38a8d8c684035/image/jpeg" style="border: 0px solid rgb(0, 0, 0); margin: 0px;" width="572" /></div>
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<img align="" alt="" height="734" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/1f56e2e1e132546dcd845b3413cb92d3/image/jpeg" style="border: 0px solid rgb(0, 0, 0); margin: 0px;" width="568" /></div>
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<img align="" alt="" height="736" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/1dc3dd81489ae559ae87d570c3ec3ade/image/jpeg" style="border: 0px solid rgb(0, 0, 0); margin: 0px;" width="571" /></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">The Choosing Wisely website also has nice accompany patient education handouts for consumers. A sample for GERD appears below.</span><br />
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<img align="" alt="" height="732" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/923b2dde0bc752eefa38970f78564532/image/jpeg" style="border: 0px solid rgb(0, 0, 0); margin: 0px;" width="566" /></div>
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<img align="" alt="" height="738" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/6acc6ce426ccd33b3ea463ddef238169/image/jpeg" style="border: 0px solid rgb(0, 0, 0); margin: 0px;" width="569" /></div>
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<img alt="" height="625" src="https://app.icontact.com/icp/loadimage.php/mogile/68461/01f5400a7da55e14a83be4afe6364cdc/image/jpeg" title="" width="480" /></div>
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<span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><span style="color: #0066ff; font-family: Verdana;"><strong> 350</strong></span></span></span></div>
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<span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><strong><span style="color: #660033; font-family: Verdana;">parts per million of atmospheric carbon compatible with a familiar, sustainable planet Earth</span></strong></span></span></div>
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<span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><strong><u>REFERENCES</u></strong>:</span></span> </span></div>
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<span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;">1.<span style="font-family: arial,helvetica,sans-serif;"> </span></span></span></span></span><span style="font-family: arial,helvetica,sans-serif;">Qaseem
A et al. Appropriate use of screening and diagnostic tests to foster
high-value, cost-conscious care. Ann Intern Med 2012; 156: 147-9.
EDITORIAL: Laine C. High-value testing begins with a few simple
questions. Ann Intern Med 2012; 156: 162-3.</span><span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><span style="font-family: arial,helvetica,sans-serif;"> </span></span></span></div>
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<span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><span style="font-family: arial,helvetica,sans-serif;">2. The <span style="font-family: Trebuchet MS;">ABIM Choosing Wisely website: </span></span></span></span><span style="font-family: arial,helvetica,sans-serif;"><a href="http://click.icptrack.com/icp/relay.php?r=&msgid=31524789&act=11111&c=68461&destination=http%3A%2F%2Fwww.choosingwisely.org%2Fdoctor-patient-lists%2F" target="_blank">http://www.choosingwisely.org/doctor-patient-lists/</a></span></div>
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<span style="font-family: arial,helvetica,sans-serif;"><strong>Article retrieval tips: </strong>To
find an article in PubMed simply enter the PMID number into the search
field. Where a 'doi' heading is listed, you can insert the doi
information into a Google search and retrieve the article.</span><br />
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Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com4tag:blogger.com,1999:blog-340176576888120508.post-22617453607753586532013-03-12T09:28:00.000-07:002013-03-12T09:28:04.963-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: center;">
<span style="font-family: Trebuchet MS, sans-serif;"><b>THE VIEW FROM THE OFFICE</b></span></div>
<div style="text-align: center;">
<span style="font-family: Trebuchet MS, sans-serif;"><b><br /></b></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_NgUKHA15B3ARJC-YfwhbtXngqtVbSP62F3SBHCpam_5N_Lt8ME1XSSPLj8d45thDhvqzbNucltY5nChFLEsa3XTTQ2KCn6PWIsKrt12m8ILA3OLssLUAdhAOaasaNOz8Udm1XtjPB68/s1600/Portola+downtown.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_NgUKHA15B3ARJC-YfwhbtXngqtVbSP62F3SBHCpam_5N_Lt8ME1XSSPLj8d45thDhvqzbNucltY5nChFLEsa3XTTQ2KCn6PWIsKrt12m8ILA3OLssLUAdhAOaasaNOz8Udm1XtjPB68/s320/Portola+downtown.jpg" width="320" /></a></div>
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<span style="font-family: Trebuchet MS, sans-serif;"><b><br /></b></span></div>
<div style="text-align: center;">
<span style="font-family: Trebuchet MS, sans-serif;"><b>IS CALCIUM AND VITAMIN D BAD FOR YOU?</b></span></div>
<div style="text-align: center;">
<span style="font-family: Trebuchet MS, sans-serif;"><b><br /></b></span></div>
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<b><u><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">THE
USPSTF HAS JUST PUT CALCIUM AND VITAMIN D IN THE DOG HOUSE</span></u></b><b><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">:</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> </span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">The USPSTF is taking abrupt action to
stop this new menace--calcium and vitamin D supplementation--in its tracks.(1)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> </span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Those
of you who have been harmed by this pernicious combination should call
1-800-BAD-DRUG.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">
</span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Actually,
we don't really know that these drugs are bad for us, it is just that there is <b><span style="color: #b50b0b;">'insufficient evidence</span></b>' to know that they're
good for us, but let's not quibble. Specifically, we can say categorically that
<b><span style="color: #090473;">there is at present no good evidence that
routine calcium and vitamin D supplementation for men or pre-menopausal women
offers any benefit for the prevention of fractures</span></b>. There may be
other benefits but these are not discussed. The Task Force adds salt to the
wound by stating '<b><span style="color: #090473;">current evidence is
insufficient to assess the balance of the benefits and harms of daily
supplementation with greater than 400 IU of vitamin D3 and greater than 1000 mg
of calcium for the prevention of fractures in non-institutionalized
postmenopausal women</span></b>. For those who have ever had the misfortune to
prescribe these, take 2 aspirin and call your lawyer. Finally, the emboldened
USPSTF takes a strong stand ("<b><span style="color: #b50b0b;">recommends
against</span></b>") on <b><span style="color: #090473;">daily
supplementation with 400 IU or less of vitamin D3 and 1000 mg or less of
calcium for the primary prevention of fractures in non-institutionalized
postmenopausal women</span></b>.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">
</span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">The
USPSTF also mentions some countervailing factors:</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">
</span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">1.
<u>They do recommend vitamin D supplementation (~800 IU/d) for the prevention
of falls</u> in community-dwelling adults aged 65 years and older who are at
increased risk for falls because of a history or recent falls or vitamin D
deficiency.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">
</span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">2.
A major meta-analysis of 31,022 adults over the age of 65 found that f<u>ractures
may be reduced (by ~ 12%) for persons taking higher doses of vitamin D
(> 800 IU/d) among both institutionalized and community-dwelling adults</u>.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">
</span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">3.
In fact, the USPSTF itself concluded in 2011 that c<u>ombined vitamin D
(300-1100 IU/d) and calcium supplementation (500 to 1200 mg/d)</u>, but not
vitamin D supplementation alone, can reduce the fracture risk in older adults.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">
</span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">4.
The Institute of Medicine and World Health Organization have <u>recommended
standards for adequate daily intake of calcium and vitamin D as a part of
overall health</u>.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">
<b><span style="color: #090473;"> </span></b></span><b><span style="color: #090473; font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">I would
suggest that this concern for overall health may be relevant for people in our
business</span></b><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">.
Preventing falls isn't a bad thing either. Calling attention to dietary and
nutritional factors in health could be construed by some as a good thing.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">
</span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">The
only harm that the USPSTF can dig up about supplementation is an increased risk
of kidney stones (estimated number needed to harm (NNH) 1/273. Perhaps we can
learn to live with this.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<b><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">COMMENT:
<span style="color: #b50b0b;">This recommendation statement is premature.</span></span></b><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> When we have good
authority to do something generally considered safe (e.g., IOM, WHO, and the
former USPSTF) it should require some very solid evidence (not just a lack of
it) to overturn established practice that could still be very health promoting
despite the Task Force's cautions. A 1/273 risk of kidney stones does not rise
to that level of evidence or harm. The problem with the USPSTF is increasingly
that, as with Orwell's elephant, they find the evidence synthesis easier to do
when inspecting only small pieces of the elephant. What we need our
recommendations to be based on are some good whole-elephant outcomes.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">
</span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">It
its consumer-oriented report of the guidelines the USPSTF does offer this
helpful aid to interpretation illustrating that their opinion should be just
one of many that goes into a consumer decision about calcium and vitamin D
supplementation.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEilb9gZ9RgYIaj-QCCjnGkt39cAVqH-wFXSqSshW9oRMM3_VyspVFZDds5_pEH_jY5DSXWdapFi2M2hv1nYIVxsNhoBvQTGnwdMjX9I6xqhVjV6oEdgtJt1nSWbhmi6ohLLw1hSN7LIar8/s1600/USPSTF.decision-making.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="217" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEilb9gZ9RgYIaj-QCCjnGkt39cAVqH-wFXSqSshW9oRMM3_VyspVFZDds5_pEH_jY5DSXWdapFi2M2hv1nYIVxsNhoBvQTGnwdMjX9I6xqhVjV6oEdgtJt1nSWbhmi6ohLLw1hSN7LIar8/s320/USPSTF.decision-making.jpg" width="320" /></a></div>
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<br /></div>
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<br /></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">
</span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">In
the meantime, what do you do?</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">
</span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">1.
<b><span style="color: #090473;">Don't change current practice</span></b>.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> </span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">There
is not enough evidence to do so.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">
</span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">2.
At a minimum <b><span style="color: #090473;">have a discussion with all patients
aged 65 years or older about the prevention of falls and the possible
prevention of fractures</span></b>.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">
</span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">3.
<b><span style="color: #b50b0b;">Don't start using more alendronate</span></b>
(or other bisphosphonates) since benefit from these is only clear for the group
of patients who have already had fragility fractures.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">
</span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">4.
Do<b><span style="color: #b50b0b;"> temper your enthusiasm for screening for
osteoporosis</span></b> since it appears that we don't know what to do about it
anymore.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">
</span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">5.<b><span style="color: #090473;"> Do fall back on exercise as the main preventive measure</span></b>.
I would, of course, assert that we should be doing this anyway...BUT WAIT, THE
USPSTF DOES NOT ENDORSE COUNSELING TO EXERCISE EITHER!(2)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<br /></div>
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<b><u><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">SHOPPERS,
IT'S SAFE TO GO NEAR THE EGGS AGAIN</span></u></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">:
</span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Chicken
eggs are high in cholesterol (about 200 mg each). It is common for providers
and experts to caution against their consumption in persons for whom
cholesterol is a clinical concern. We have a new meta-analysis of 17
prospective cohort studies in which egg consumption was measured with
food-frequency questionnaires; patients were followed for 10 to 20 years of
follow-up.(3)<b><span style="color: #b50b0b;"> No associations between egg
consumption and risk for either heart disease or stroke were observed</span></b>.
For the subgroup of diabetics, egg consumption increase the risk of heart
disease (RR, 1.5) and lower the risk of stroke (RR, 0.80). COMMENT: Eat your
eggs.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<br /></div>
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<b><u><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">DIET
DOES MATTER</span></u></b><b><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">:
</span></b><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Despite
the USPSTF's apparent opposition, interventions to promote a healthy diet (in
this case, specifically a Mediterranean diet) have some significant benefits.
We've all known about the substantial benefits of a Mediterranean diet for
years. Here we have another confirmation.(3) Spanish investigators conducted a
multicenter trial in which 7447 high-risk patients were randomly assigned to
one of 3 interventions: (1) a Mediterranean diet supplemented with extra-virgin
olive oil; (2) a Mediterranean diet supplemented with mixed nuts; or (3) a
control diet. Participants received quarterly individual and group educational
sessions and, depending on group assignment, free provision of extra-virgin olive
oil, mixed nuts, or small non-food gifts. The primary end point was the rate of
major cardiovascular events (MI, CVA, or death from CV causes). <b><span style="color: #090473;">On the basis of the results of an interim analysis, the
trial was stopped after a median follow-up of 4.8 years</span></b>. <b><span style="color: #090473;">The multivariable-adjusted hazard ratios were 0.70 and
0.72 for the group assigned to a Mediterranean diet with extra-virgin olive oil
and the group assigned to a Mediterranean diet with nuts, respectively</span></b>.
COMMENT: This worked very nicely. How are you going to get patients to even try
a nice health diet like this if you don't counsel them? Tell me that,
USPSTF!</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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atmospheric carbon compatible with a familiar, sustainable planet Earth</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<b><u><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">REFERENCES</span></u></b><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">: </span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">1.
USPSTF. Vitamin D and calcium supplementation to prevent fractures in adults:
Clinical summary of US Preventive Services Task Force Recommendation. </span><a href="http://www.blogger.com/blogger.g?blogID=340176576888120508"><span style="color: blue; font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">www.uspreventiveservicestaskforce.org/uspstf12/vitamind/vitdsumm.htm</span></a><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">. </span><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Chung M et al for the USPSTF. Vitamin D with or without
calcium supplementation for prevention of cancer and fractures: An updated
meta-analysis for the USPSTF. Ann Intern Med 2011; 155: 827-38. Moyer VA for
the USPSTF. Vitamin D and calcium supplementation to prevent fractures in
adults: </span><a href="http://www.blogger.com/blogger.g?blogID=340176576888120508"><span style="color: blue; font-family: "Arial","sans-serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">US Preventive services Task Force Recommendation Statement. Ann
Intern Med</span></a><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> 2013; Feb 26. </span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">2. USPSTF.Behavioral Counseling to
Promote a Healthful Diet and Physical Activity for Cardiovascular Disease
Prevention in Adults</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">.</span><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> </span><a href="http://www.blogger.com/blogger.g?blogID=340176576888120508"><span style="color: blue; font-family: "Arial","sans-serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">http://www.uspreventiveservicestaskforce.org/uspstf/uspsphys.htm</span></a><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">3.
</span><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Rong Y et al. Egg consumption and
risk of coronary heart disease and stroke: Dose-response meta-analysis of
prospective cohort studies. <i>BMJ</i> 2013 Jan 7; 346:e8539. (</span><a href="http://www.blogger.com/blogger.g?blogID=340176576888120508"><span style="color: blue; font-family: "Arial","sans-serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">http://dx.doi.org/10.1136/bmj.e8539</span></a><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">4. Estruch R et al. Primary
prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med
2013 Feb 25. PMID: 23432189.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com5tag:blogger.com,1999:blog-340176576888120508.post-53374217938073246652012-11-20T13:43:00.002-08:002012-11-20T13:43:44.199-08:00<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: Trebuchet MS, sans-serif;"><b>A VIEW FROM THE OFFICE</b></span></div>
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<span style="font-family: Trebuchet MS;"><strong>IF PATIENTS KNEW WHAT THEY'RE SUPPOSED TO KNOW, </strong></span></div>
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<span style="font-family: Trebuchet MS;"><strong>WOULD THEY WANT WHAT WE OFFER?</strong></span></div>
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<span style="font-family: Trebuchet MS;"><strong><u>CONSUMER RATINGS OF 4 PREVENTIVE INTERVENTIONS</u>: </strong></span><span style="font-family: trebuchet ms,helvetica,sans-serif;">The best way to understand the importance of this new study in <em><strong>Annals of Family Medicine</strong></em>(1)</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">is to take the same survey as the report subjects (354 persons of 977 invited, aged 50-70 from 3 GP practices in New Zealand</span>. <span style="font-family: trebuchet ms,helvetica,sans-serif;">Four
standard clinical interventions are evaluated: prevention of hip
fractures, prevention of breast and colon cancer, and prevention of
heart attacks (from treatment of HTN and hyperlipidemia). Here is your Quiz:</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"><u><strong>Example A</strong></u>: 5,000 men and women aged between 50 and 70 years diagnosed with <span style="color: #1b0b99;"><strong>osteoporosis</strong></span> are given medication for 10 years to reduce the <strong><span style="color: #1b0b99;">risk of fractures</span></strong>. </span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">1. From this group, approximately how many hip fractures do you expect would be prevented by taking this medication?</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">(a) 1</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;"> (b) 5 (c) 50 (d) 100 (e) 500 (f) 1000</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"><u><strong>Example B</strong></u>: 5,000 men and women aged between 50 and 70 years from the general population are screened for <strong><span style="color: #1b0b99;">bowel cancer</span></strong> regularly for 10 years.</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">2.
From this group, approximately how many deaths due to bowel cancer do
you expect would be prevented by screening people for bowel cancer?</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">(a) 1</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;"> (b) 5 (c) 50 (d) 100 (e) 500 (f) 1000</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"><u><strong>Example C</strong></u>:
5,000 men and women aged between 50 and 70 years from the general
population are given medication for 10 years to decrease their <strong><span style="color: #1b0b99;">risk of dying of cardiovascular disease</span></strong>.</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">3.
From this group, approximately how many deaths due to cardiovascular
disease do you expect would be prevented by taking this medication?</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">(a) 1</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;"> (b) 5 (c) 50 (d) 100 (e) 500 (f) 1000</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"><u><strong>Example D</strong></u>: 5,000 women aged between 50 and 70 years from the general population are screened for <strong><span style="color: #1b0b99;">breast cancer</span></strong> regularly for 10 years.</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">4. For this group, approximately how many deaths due to breast cancer do you expect would be prevented by participation in the screening program?</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">(a) 1</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;"> (b) 5 (c) 50 (d) 100 (e) 500 (f) 1000</span></div>
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<span style="color: #bd0b2f;"><strong> </strong></span><span style="font-family: trebuchet ms,helvetica,sans-serif;"><span style="color: #bd0b2f;"><strong>Alright now, go ahead and commit to an answer (single answer for each one).</strong></span> [Tip: You will get credit for the number closest to the actual value whether on the high side or low side.]</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"><strong><u>Answer Key</u>:</strong></span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">"<strong>Hip Fracture Prevention</strong>: Alendronate achieves a 53% relative risk reduction for hip fracture among those at high risk of fracture. There is little evidence for the benefit of bisphosphonates
beyond 5 years of use, but 1 study that examined use up to 10 years
found no significant difference in risk between those treated for 5 and
10 years. <strong><span style="color: #1b0b99;">The average 10-year hip fracture risk for a 60-year old woman has been calculated as 2.3%</span></strong>. If we assume this risk for the hypothetical group of 5,000 people treated for 10 years, <strong><span style="color: #116600;">then the number of fractures we would expect to avoid would be 54</span></strong>. We considered 50 to be the correct answer, 1 or 5 to be an underestimate, and 100, 500, or 1,000 to be overestimates."</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">"<strong>Bowel Cancer Screening</strong>: Bowel cancer screening using fecal occult blood testing (FOBT) reduces bowel cancer mortality. <span style="color: #1b0b99;"><strong>The absolute reduction in bowel cancer</strong></span></span><span style="color: #1b0b99;"><strong> <span style="font-family: trebuchet ms,helvetica,sans-serif;">in bowel cancer mortality with FOBT screening is 1 go 2 deaths avoided per 1,000 people screened over 10 years.</span></strong></span><span style="font-family: trebuchet ms,helvetica,sans-serif;"> For the example in the questionnaire, <span style="color: #116600;"><strong>the correct range of number of deaths avoided would therefore be 5 to 10</strong></span>. We considered answers of 5 to be correct, 1 to be an underestimate, and 50,100, 500 or 1,000 to be overestimates.</span>"</div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">"<strong>Cardiovascular Disease Prevention</strong>: Treatment of hypertension and hyperlipidemia in primary prevention of cardiovascular disease reduces morbidity and mortality. <strong><span style="color: #1b0b99;">Antihypertensive medications achieve a 13% relative reduction in mortality, and statins achieve relative reductions in mortality of 12% to 17% (absolute reductions of 0.15 to 0.17 deaths per 100 per year).</span></strong> For the example in the questionnaire, <strong><span style="color: #116600;">the correct range of number of deaths avoided would be 75 to 85</span></strong>. We considered 50 or 100 to be correct answers, 1 or 5 to be underestimates, and 500 or 1,000 to be overestimates."</span> </div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">"<strong>Breast cancer screening</strong>: Estimates of <strong><span style="color: #1b0b99;">breast cancer mortality reduction with 10 years of screening range from 1 death avoided for every 337 women screened to 1 death avoided for every 2,500</span></strong>. for the example in the questionnaire, <strong><span style="color: #116600;">the correct range of number of deaths avoided would therefore be 2 to 15</span></strong>. We considered estimates of 1 or 5 as being correct and 50, 100, 500 or 1,000 to be overestimates.</span><span style="font-family: trebuchet ms,helvetica,sans-serif;">"</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">OK.
So how did you do? My guess is that the average practicing primary care
physician is likely only to get 1 out of the 4 questions correct.</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"></span> <span style="font-family: trebuchet ms,helvetica,sans-serif;"><b><span style="color: red;">But now comes the real kicker</span></b>. The authors of this study then asked the same survey respondents for their own opinions--<strong><span style="color: #1b0b99;">How many deaths would need to be avoided, in their personal opinion, for each intervention to be worthwhile?</span></strong></span> <span style="font-family: trebuchet ms,helvetica,sans-serif;"></span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">For <strong>hip fracture prevention</strong>, <strong><span style="color: #1b0b99;">64% of subjects thought you needed to prevent at least 100 fractures over 10 years for the intervention to be worthwhile</span></strong>.
This implies that a majority of subjects would decline the intervention
if they were informed of the true absolute value. They are simply not
impressed with the value of the intervention.</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">For <strong>bowel cancer prevention,</strong></span> <strong><span style="color: #1b0b99;"><span style="font-family: trebuchet ms,helvetica,sans-serif;">73% of the subjects thought that you need to prevent at least 100 deaths from bowel cancer</span></span></strong>, <span style="font-family: trebuchet ms,helvetica,sans-serif;">which is significantly greater than the benefit actually achieved.</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"> For <strong>cardiovascular disease prevention</strong>, <strong><span style="color: #1b0b99;">46% of the subjects thought that you need to prevent at least 500 cardiovascular deaths for the intervention to be worthwhile</span></strong>. <strong><span style="color: #116600;">Cardiovascular disease prevention</span></strong>, of the 4 interventions analyzed, <strong><span style="color: #116600;">had
the highest number of subjects who estimated a number of deaths that
should be avoided correctly for the intervention to be worthwhile--28%
of subjects chose either 50 or 100, which are consistent with the actual
data</span></strong>.</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">For <strong>breast cancer prevention</strong>, <strong><span style="color: #1b0b99;">69%
of subjects thought that at least 50 deaths from breast cancer should
be avoided over 10 years of screening for the intervention to be
worthwhile</span></strong> whereas the actual benefit in deaths avoided is only 1-5.</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"></span><span style="font-family: trebuchet ms,helvetica,sans-serif;"><strong>COMMENT: </strong>For
me informed consent is the key issue and is where we fail our patients
most often. The information that patients want to know and should know
is what is the general probability that any screening intervention will
actually benefit them. Below a certain idiosyncratic threshold they are
just not interested. This study shows that a substantial majority of
patients would not be interested in these 4 common interventions if
appropriately provided with the facts. A key part of the problem is that
most physicians are as 'innumerate' as patients are and simple don't
know what the risks (incidence) and absolute mortality are with and
without screening; this has been amply demonstrated by Gil Welch's book, "<em><strong>Overdiagnosed</strong></em>."(2)</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">You can use your own performance on the 4 question survey above to assess the adequacy of your information. </span><span style="font-family: trebuchet ms,helvetica,sans-serif;">If you're not satisfied with your performance, you can rectify it with Dr. Welch's very entertaining book.</span></div>
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<span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><strong><u>REFERENCES</u></strong>:</span></span> </span></div>
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<span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;">1. </span></span>Hudson B et al. Patients' expectations of screening and preventive treatments. Ann Fam Med 2012; 10: 495-502. doi:10.1370/afm.1407. A free copy of the survey instrument is available online at <a data-cke-saved-href="http://annfammed.org/content/10/6/495/suppl/DC1" href="http://www.blogger.com/blogger.g?blogID=340176576888120508">http://annfammed.org/content/10/6/495/suppl/DC1 </a></span></span></div>
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<span style="font-family: Trebuchet MS;">2. Welch GH. Overdiagnosed: Making people sick in the pursuit of health. Beacon Press. Boston. 2011.</span></div>
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Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com3tag:blogger.com,1999:blog-340176576888120508.post-84782160381586292012012-10-23T12:20:00.000-07:002012-10-23T12:20:27.182-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: Trebuchet MS, sans-serif;"><b>A VIEW FROM THE OFFICE</b></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSny7pzoUddD11Kyb9rfX5mSJwfUoF3YqB3j-FqOhLx0KhxbnVOZYCVRdKSsahmnevFqQfk-PLiuOZrlReNsOxW8-n8iduGU4qPA0LI6CT5030PsiyDN8giiFYeJhk_WXJR4cxj5Wc_Tk/s1600/Portola+View+from+the+Office.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSny7pzoUddD11Kyb9rfX5mSJwfUoF3YqB3j-FqOhLx0KhxbnVOZYCVRdKSsahmnevFqQfk-PLiuOZrlReNsOxW8-n8iduGU4qPA0LI6CT5030PsiyDN8giiFYeJhk_WXJR4cxj5Wc_Tk/s320/Portola+View+from+the+Office.jpg" width="320" /></a></div>
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<span style="font-family: Trebuchet MS, sans-serif;"><b>SHOULD PATIENTS BE ABLE TO READ THEIR DOCTORS' NOTES?</b></span></div>
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<b><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><span style="background-color: cyan;">TALK
ABOUT REVOLUTIONARY, SHOULD WE LET PATIENTS READ THEIR DOCTORS' NOTES?</span> </span></b><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">In the first study (The OpenNotes Project) of
its kind that I've seen, for one year primary care practices at Beth Israel
Deaconess Medical Center in Massachusetts, Geisinger Health System in
Pennsylvania, and Harborview Medical Center in Washington provide their
patients with a link to the physician 'notes' part of the medical record.(2)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> </span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Among the study group, 11,797 of 13,564
patients opened at least 1 physician note. 77-87% of patients reported that
this experience helped them feel more in control of their care; 60-78% of those
taking medications reported increased medication adherence; 1% to 8% reported
that the notes caused confusion, worry, or offense. 20% to 42% shared their
notes with others. Overall the volume of electronic messages from
patients to their physicians did not change.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><br />
</span><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">On
the physician side, 3% to 36% of doctors reported changing documentation
content, and 0% to 21% reported taking more time writing notes. <br />
</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> </span><b><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Trouble ahead</span></b><span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">: 59% to 62% of
patients believed that they should be able to add comments to a doctor's note.
One out of 3 patients believed that they should be able to approve the notes'
contents, but 85% to 96% of doctors did not agree. At the end of the
experimental period, 99% of patients wanted open notes to continue and no
doctor elected to stop.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> </span></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><br /></span></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><b><span style="background-color: cyan;">A PATIENT'S PERCEPTION (AN ATTORNEY WORKING IN THE HEALTH CARE FIELD)</span>: </b>"I remember ... history when I hear doctors object to making lab reports or visit notes available to patients because they may cause pain and anxiety. No doubt they will in some cases, but then pain and anxiety are part of the human condition and are as likely to be produced by a sense of ignorance and powerlessness as by knowledge. The difference turns on who decides. People have myriad ways of protecting themselves from things they don't want to know. making information freely available doesn't necessarily mean that patients will be forced to learn what they'd rather ignore. The Internet is a model here: Some people devour the plethora of medical information; others avoid it like the plague. If any generalization suffices, to treat patients like adults requires that we, not a well-meaning professional, make the choice between more and less knowledge...</span></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> "Doctors are concerned that writing notes patients can read may take up valuable time and stimulate questions that in turn will take time to answer. Such concerns are serious, but data from the OpenNotes project strongly suggest that they are overblown. doctors already have to take notes and answer questions. The key here is not more or less time, but best practices. Is in not better in most cases to have an informed patient, one who can correct errors, clarify confusion, understand the effects of medications, and be able to discuss specific treatments with family and friends?...</span></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> "Doctors may fear that openness will lead to lawsuits, but there is no credible evidence that patients will rush to the courthouse. Secrecy, and a sense that the doctor is distant or indifferent, stimulates litigation as much as a free flow of information. If that flow improves trust, the likelihood is fewer lawsuits. Make no mistake: Previously dormant errors will be uncovered--that's the way with more information. But to the extent that tho0se errors are substantial, a profession that prides itself on correcting mistakes can hardly oppose broadening the opportunity to expose them...</span></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> "For an open system of information to realized its potential, physicians will have to make sure they don't overstep the bounds of their power, whereas patients will have to take more responsibility for what they know and do and, ultimately, for how their lives affect their health. Opening complicated systems to greater client participation always includes dislocation. Here, the benefits that come from a greater flow of information hold considerable promise for creating a healthier society, a result that is plainly worth the costs."</span></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><b><span style="background-color: cyan;">A JOURNAL EDITOR'S VIEW:</span> </b>"Use of electronic health record systems is increasing at a rapid pace, with the percentage of physicians using such systems in their practices rowing from 17% in 2008 to 34% in 2011 [mainly thanks to Obama]...</span></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> "Although patients technically 'own' their medical records, processes for obtaining them have been arduous and many patients do not avail themselves routinely of this service. Physicians and other professional staff have therefore traditionally viewed medical records as primarily for their use, as a means of documenting care for future reference and of communicating with other providers, and have not worried much about how that documentation might affect the patient. Given this background, the physicians' apprehension about the consequences of having their notes electronically accessible to patients is understandable.</span></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> "But a revolution is occurring in health care documentation with the widespread implementation of electronic medical records, particularly the development of patient portals. Patients, many of whom already have access to some electronic medical information, have become savvy consumers of online health information, and will demand more. The way that we as physicians view the medical records needs to change accordingly....</span></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> "The OpenNotes project identifies a number of issues that should be evaluated to understand the full value of free access to physician notes. What is the effect on provider-to-provider communication if they modify their documentation practices because of concerns about patient reactions? Will this impair the ability of other providers to manage patients appropriately? If OpenNotes is expanded in scope, what is the impact on physician time and documentation?...</span></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> "OpenNotes is a brave effort at pushing the frontier of patient engagement in their health. While an experiment like this raises concerns for many physicians, the strong message from patients is that it makes them better patients."</span></div>
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<span style="font-family: 'Times New Roman', serif; font-size: 12pt;"> </span><span style="font-family: 'Trebuchet MS', sans-serif; font-size: 12pt;"><b>COMMENT</b>: This is perhaps a somewhat frightening view of the future. I think it is inevitable that this happens, and I personally am all for it. A doctor's visit should be a collaborative enterprise. The record of it is so important (since all details of the visit are forgotten by both sides pretty quickly). Patients should have the right to add comments, explain and clarify their story more, and to ask questions, if they have any. I certainly don't believe that patients have any rights to approve or veto the notes; instead they have a right to change physicians. Overall, writing notes with the notion that patients are looking over your shoulder should lead to a better doctor-patient relationship and higher quality information.</span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif; font-size: 12pt;"> The additional views expressed by a patient and a journal editor with very different perspectives nicely complements this innovative research. <span style="color: blue;"><b>The bottom line is that patients clearly like this practice, and physicians, while apprehensive, are not finding any significant impairment in their work, and, in fact, at the end of this study, no physician opted to stop the sharing of medical records</b></span>.</span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif; font-size: 12pt;"> Good health care has always been a shared enterprise between physician and patient. Errors and misunderstandings have always plagued our work and not enough time has often truncated the information that patients would have liked to share with us. This new way of using electronic medical records offers a solution to these problems. Physicians will inevitably step down from a high pedestal to a lower one, and patients will have to step up to more responsibility for their care. The result, if we all do our jobs with openness and tolerance, will be far better health care and ultimately far better health outcomes.</span></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">References:</span></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">1. Delbanco T et al. Inviting patients to reader their doctors' notes: a quasi-experimental study and a look ahead. Ann Intern Med 2012; 157: 461-70.</span></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">2. Meltsner M. JD. A patient's view of OpenNotes. Ann Intern Med 2012; 157: 523-4.</span></div>
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<span style="font-family: "Trebuchet MS","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">3. Goldzweig CL. Pushing the envelope of electronic patient portals to engage patients in their care. Ann Intern Med 2012; 157: 526-6.</span></div>
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Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com4tag:blogger.com,1999:blog-340176576888120508.post-38807731526269398162012-09-25T11:01:00.001-07:002012-09-25T11:01:32.747-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: Trebuchet MS;"><strong>A VIEW FROM THE OFFICE</strong></span></div>
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<span style="font-family: Trebuchet MS;"><strong> </strong></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpVUPLAJAFAYHiq6900qe07eOGlAHFw5TdS_eFA-PEkIGBL9m_yDNHElrgzy7q2fIOGwe9FucWJiPBYEvuEEZBMmTenCIU2Hv_dZ3LBNQ5R9u5r2isi-oEjK6JO2MA4Z9V010VBtzNjJ4/s1600/Viewfromoffice2.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpVUPLAJAFAYHiq6900qe07eOGlAHFw5TdS_eFA-PEkIGBL9m_yDNHElrgzy7q2fIOGwe9FucWJiPBYEvuEEZBMmTenCIU2Hv_dZ3LBNQ5R9u5r2isi-oEjK6JO2MA4Z9V010VBtzNjJ4/s320/Viewfromoffice2.JPG" width="320" /></a></div>
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<span style="font-family: Trebuchet MS;"><strong>WHAT FORMS OF PREVENTION ARE OUR NATIONAL EXPERTS RECOMMENDING NOW?</strong></span></div>
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<span style="font-family: Trebuchet MS;"><strong>PUBLICATION NOTICE</strong></span></div>
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<span style="font-family: Trebuchet MS;"><strong>NOTICE: </strong>Please be aware that the previous website associated with this publication (www.Kopes-eticHealth.com) has been removed. The new website for information about this and other publications is <a data-cke-saved-href="http://www.FPRevolution.net" href="http://www.fprevolution.net/">www.FPRevolution.net</a>. </span><span style="font-family: trebuchet ms,helvetica,sans-serif;">Also note that long-time email address of <span style="color: blue;">cpkerr@nni.com</span> is no longer valid. The new preferred email address appears above.</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"><strong>NEW INDEX OF ALL BACK ISSUES AVAILABLE: </strong>An Adobe PDF
file containing all back issues through September 2012 is now available
along with a companion index file that allows searching in Adobe
Reader. To obtain a copy of these files please send an email to the
address above with the words "<strong>Back Issues</strong>" in the subject line.</span></div>
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<span style="color: #041b4a;"><span style="color: #041569;"><span style="font-family: trebuchet ms,helvetica,sans-serif;"><strong>THE CRAZINESS OF THE US PREVENTIVE SERVICES TASK FORCE</strong></span></span></span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">While the USPSTF
is the best source of a summary of the evidence relating to the most
common important health interventions, they are far less competent at
marshaling the evidence to make a sound recommendation. They sometimes
miss the forest for the trees.</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">I have recently discussed at length the major problem with their recently updated guideline of <span style="color: #041569;"><strong>counseling for physical activity</strong></span>. Well, they have done it again--this time regarding <strong><span style="color: #041569;">counseling for improved nutritional behaviors in primary care</span></strong>.
To make really clear the folly of their position on these two important
issues I will contract these new guidelines with their recent guideline
on counseling for behavioral changes to prevent skin cancer.</span></div>
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<strong><span style="font-family: trebuchet ms,helvetica,sans-serif;">BEHAVIORAL COUNSELING TO PREVENT SKIN CANCER: </span></strong><span style="font-family: trebuchet ms,helvetica,sans-serif;">The USPSTF is concerned because more than <strong><span style="color: #041569;">2 million cases of skin cancer</span></strong>
are diagnosed annually in the United States. Most of these (two-thirds)
are basal cell skin cancer, which is not associated with significant
mortality. <strong><span style="color: #041569;">Basal cell carcinoma accounts for less than 0.1% of patient deaths due to cancer</span></strong>. The USPSTF expresses specific concern about the rising incidence of melanoma without acknowledging that most of this is due to overdiagnosis [See Dr. Gil Welch, "<strong><em>Overdiagnosed</em></strong>",
previously reviewed here this year: Chapter 5.] Increased screening and
biopsy has led to an increase in diagnosed cases, but there has, as
yet, been no accompanying reduction in mortality, which overall suggest
much ado about nothing. The patient behaviors that are the focus of this
guideline are the use of sunscreen and avoidance of indoor tanning. </span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">"Sunprotective
counseling in primary care varies in frequency and content, despite
data suggesting that these behaviors need to be improved." (This is
based on the observation than not many people consistently engage in
such behaviors, not on any evidence that such behaviors actually work.)
Against this would be the observation that "<strong><span style="color: #041569;">most
existing studies did not suggest a strong association between total or
chronic sun exposure and squamous cell carcinoma or basal cell carcinoma</span></strong>."
So how is counseling to avoid sun exposure expected to do any good? As
to the existing evidence of the effectiveness of counseling to avoid sun
exposure, the USPSTF notes: "<strong><span style="color: #041569;">Evidence
in adults and parents of newborns suggests that behavioral
interventions can minimally increase composite scores measuring sunprotective behaviors. It is unclear, however, whether the small differences in composite scores of self-reported sunprotective behaviors translate into clinically meaningful behavior change to prevent skin cancer or sunburns</span></strong>."</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">This last statement would seem to indicate that as yet no routine counseling for sunprotective behaviors is as yet ready for prime time.</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">Nonetheless <u>the USPSTF
recommends counseling children, adolescents, and young adults aged 10
to 24 years who have fair skin about minimizing their exposure to
ultraviolet radiation to reduce risk for skin cancer</u>. They do not recommend such counseling for those older than 24 years (insufficient evidence). </span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">Thus in this recommendation statement the USPSTF
seems willing to suggest that all physicians treating persons aged 0-24
years should modify their practices to include counseling in order to
avoid a small risk with an intervention that has small evidence of a
small effect. They find no evidence of harms from the recommended
intervention, not even "the lost opportunity to provide other services
that have a greater health effect."</span></div>
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<strong><span style="font-family: trebuchet ms,helvetica,sans-serif;">BEHAVIORAL
COUNSELING INTERVENTIONS TO PROMOTE A HEALTHFUL DIET AND PHYSICAL
ACTIVITY FOR CARDIOVASCULAR DISEASE PREVENTION IN ADULTS: </span></strong> <span style="font-family: trebuchet ms,helvetica,sans-serif;">On
the subject of counseling interventions to promote a healthful diet and
physical activity for cardiovascular prevention (an admittedly far more
important health priority), the USPSTF is not so tolerant of an incomplete database even though 49.7</span><span style="font-family: trebuchet ms,helvetica,sans-serif;">% of US adults older than 20 years have at least one of the following CVD risk factors: uncontrolled hypertension, uncontrolled elevated LDL cholesterol levels, or current smoking. "<strong><span style="color: #041569;">Although the correlation among healthful diet, physical activity, and the incidence of CVD is <u>strong</u>,
existing evidence indicates that the health benefit of initiating
behavioral counseling in the primary care setting to promote a healthful
diet and physical activity is <em>small</em></span></strong>."</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">Do they mean smaller than the benefit of recommending sunprotective behaviors? "<strong><span style="color: #041569;">All persons, regardless of risk status for CVD, can benefit from improved nutrition, healthy eating behaviors, and increased physical activity</span></strong>,"</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">but they are not going to recommend any interventions to promote such behaviors. It is certainly non-intuitive that the USPSTF
believes that spending our time to try to reduce the limited risk of
skin cancers is worthwhile, but routine counseling to prevent heart
disease is not.</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">The USPSTF acknowledges that "<strong><span style="color: #041569;">in adult patients without known hypertension, diabetes, hyperlipidemia, or CVD,
there is adequate evidence that the benefits of medium- to
high-intensity behavioral counseling interventions to improve diet and
increase physical activity are small to moderate</span></strong>...<strong><span style="color: #041569;">The USPSTF
concludes with moderate certainty that medium- or high-intensity
behavioral counseling interventions in the primary care setting to
promote a healthful diet and physical activity have a small net benefit
in adult patients without CVD, hypertension, hyperlipidemia, or diabetes</span></strong>."</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">The <strong>intensity </strong>of the intervention was categorized by total patient contact time as <strong>low </strong>(1 to 30 minutes), <strong>medium </strong>(31 to 360 minutes), or <strong>high </strong>(>
360 minutes). For some reason they did not analyze their recommendation
to counsel persons aged 0 to 24 by the required intensity of
intervention required to have an effect. </span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">The USPSTF does recommend intensive behavioral dietary counseling for adult patients with hyperlipidemia
and other known risk factors for cardiovascular and diet-related
chronic disease. In order to address patient risk factor status, they
implicitly recommend routine screening or assessment for cardiovascular
risk using such risk calculators as the Framingham-based Adult Treatment Panel III calculator (available at <a data-cke-saved-href="http://hp2010.nhlbihin.net/atpiii/calculator.asp" href="http://hp2010.nhlbihin.net/atpiii/calculator.asp">http://hp2010.nhlbihin.net/atpiii/calculator.asp</a>) </span><span style="font-family: trebuchet ms,helvetica,sans-serif;">along with routine lipid screening and screening for obesity. An important point that the USPSTF
appears to miss completely is that these latter activities require
time. For the first 15 years of my practice I was ardent in performing
routine cardiac risk assessment. I found it time consuming even without
an intervention. I finally made the decision, based purely on efficiency</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">concerns</span>, <span style="font-family: trebuchet ms,helvetica,sans-serif;">to
skip the risk assessment component and to proceed directly to routine
universal counseling for nutrition, exercise, and a healthy lifestyle
for all patients, aged 4 to 100 years. This latter approach requires no
more time than routine cardiac risk assessment yet includes the relevant
intervention.</span></div>
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T<span style="font-family: trebuchet ms,helvetica,sans-serif;">he USPSTF
declares that their lack of enthusiasm for nutrition, exercise, or
lifestyle counseling is based not on the merits of the health benefits</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">of physical activity, but on lack of clear evidence of the effectiveness of the counseling</span>. <span style="font-family: trebuchet ms,helvetica,sans-serif;">This
aspect of their recommendation reveals a major flaw in their analysis.
They pay no attention to the now abundance evidence of the effectiveness
of brief motivational interviewing. The evidence of the effectiveness
as well as the details on the "how to" are well summarized in Rollnick. [</span><span style="font-family: trebuchet ms,helvetica,sans-serif;"><a data-cke-saved-href="http://search.barnesandnoble.com/Motivational-Interviewing-in-Health-Care-Stephen-Rollnick/e/9781593856120?r=1&cm_mmc=GooglePLA-_-Textbook-_-Q000000633-_-9781593856120&cm_mmca2=pla" href="http://search.barnesandnoble.com/Motivational-Interviewing-in-Health-Care-Stephen-Rollnick/e/9781593856120?r=1&cm_mmc=GooglePLA-_-Textbook-_-Q000000633-_-9781593856120&cm_mmca2=pla">http://search.barnesandnoble.com/Motivational-Interviewing-in-Health-Care-Stephen-Rollnick/e/9781593856120?r=1&cm_mmc=GooglePLA-_-Textbook-_-Q000000633-_-9781593856120&cm_mmca2=pla</a></span>] <span style="font-family: trebuchet ms,helvetica,sans-serif;">A handy 34 page guide to the technique is available free at </span><a data-cke-saved-href="http://www.psychmap.org/uploads/Motivational%20Interviewing%20brief%20guide.pdf" href="http://www.psychmap.org/uploads/Motivational%20Interviewing%20brief%20guide.pdf"><span style="font-family: trebuchet ms,helvetica,sans-serif;">http://www.psychmap.org/uploads/Motivational%20Interviewing%20brief%20guide.pdf</span></a>. <span style="font-family: trebuchet ms,helvetica,sans-serif;">While
a brief motivational interviewing is a relatively new technology [for
which the majority of practicing physicians received no training at all]
the evidence of effectiveness or just a 2-3 minute intervention on a
repeated basis is compelling. It is currently that standard of care for
changing behavior in health settings. The USPSTF needs to perform an
evidence-review and recommendation of this technique and then reconsider
their complete dismissal of low intensity interventions for diet and
exercise counseling. Moreover, they need to explicitly consider that
fact that regularly repeated brief motivational interviewing
cumulatively constitutes a high-intensity counseling intervention. </span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">One final USPSTF
point against routine counseling for diet and exercise derives from a
potential harm of such counseling--"Harms may include the lost
opportunity to provide other services that have greater health effect."
This is a criterion that was not applied to their endorsement of
counseling to promote sunprotective behavior between ages 0 and 24 years. Do they really believe that counseling for sunprotective
behaviors has a greater effect than counseling for diet, exercise, or
lifestyle? Once again I would like to remind readers of the benefits of a
5-element healthy lifestyle (based on 16 observational studies):</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"><img data-cke-saved-src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/2b7f9466e419f813a015689b00cfb119/image/jpeg" src="https://staticapp.icpsc.com/icp/loadimage.php/mogile/68461/2b7f9466e419f813a015689b00cfb119/image/jpeg" /></span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"><strong>COMMENT</strong>: How on earth does the USPSTF
reach the conclusion that these health benefits are not compelling or
that appropriately performed brief motivational interviewing is not
effective in leading to the related behavior changes? In part this is
because they have broken down their analysis </span><span style="font-family: trebuchet ms,helvetica,sans-serif;">by
individual components rather than by a simple global definition of a
health lifestyle. This is important because such healthy behaviors have
dramatic synergistic effects.</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">The approach taken by the USPSTF
suffers from a failure to prioritize recommendations based on the
magnitude of health benefits and from the failure, where the
evidence-base is still limited, to make recommendations based on
relevant but lower quality studies such as the 16 observational studies </span><span style="font-family: trebuchet ms,helvetica,sans-serif;">that support the list of benefits above. To some extent Pascal's wager should apply to medicine. I would phrase it this way. <strong><span style="color: #041569;">If
there is any possibility that the above benefits are real, then
physicians should routinely recommend the 5 lifestyle behaviors to
everyone just because the harms are nil</span></strong>.</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"><strong>SCREENING FOR AND MANAGEMENT OF OBESITY IN ADULTS: </strong></span><span style="font-family: trebuchet ms,helvetica,sans-serif;">According to the USPSTF,
while we should do no routine counseling for diet, exercise, or a
healthy lifestyle, we should routinely screen adults for obesity.</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">"<strong><span style="color: #041569;">The USPSTF recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions</span></strong>...The USPSTF
concludes with moderate certainty that screening for obesity in adults
has a moderate net benefit." This recommendation is ultimately based
primarily on the fact that "intensive, multicomponent behavioral
interventions for obese adults can lead to an average weight loss of 4
to 7 kg...[and] also improve glucose tolerance and other physiologic
risk factors for cardiovascular disease." </span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">The USPSTF
does not explain why it believes it is more important to screen for
obesity than to prevent it (i.e., with diet, exercise, and lifestyle
interventions). </span><span style="font-family: trebuchet ms,helvetica,sans-serif;">We
have no data on the efficacy of obesity prevention because it has never
been tried. One of the reasons that it has never been tried is that
expert organizations like the USPSTF don't recommend it. They say they
don't recommend it because there is insufficient evidence, and this
leaves us in a 'Catch 22' situation.</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">Nor has it adequately answered the compelling critique of its last obesity recommendation in 2004. At that time an editor for <em><strong>Journal Watch</strong></em> commented:</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">"<strong><span style="color: #d6223a;">Despite good evidence these recommendations will be difficult to implement. First BMI
calculation requires measurement of height, which is not obtained
routinely in adults. Second, and more important, medication and surgery
are effective, but their use is limited to the severely obese, and
surgery is not without risk. In addition, pharmacologic therapies should
be given in the context of counseling; however high-intensity
counseling (for which there is the best evidence) generally is available
only by referral, is of limited availability, and requires substantial
patient commitment</span></strong>."(4)</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">Finally, we're missing the point that <strong><span style="color: #041569;">the obese know who they are</span></strong>. In a practice-based study in 1998 among 755 consecutive patients of a single practice, all obese patients (BMI > 30) were aware that they were overweight. Physician estimate of BMI (without actual measurement) turned out to be reasonably sensitive (70%), specific (99%), and predictive of measured BMI (93% PPV).(5)</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">Why
would physicians need to spend their time screening for a condition
that is obvious and certainly known to patients? The futility of
screening is highlighted by the fact that there are no proven treatments for obesity in the primary care setting</span>. <span style="font-family: trebuchet ms,helvetica,sans-serif;">Either high-intensity counseling outside of the physician's office or a referral for a surgical-based approach are required.</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">COMMENT: The USPSTF has missed the boat. Somehow their principles or internal guidelines don't allow them</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">to
probe beyond the highest quality studies or to base their guidelines on
heuristic principles. The fact that they endorse counseling for sunprotective
behaviors and screening for obesity over what they know to be the sound
principle of leading a healthy lifestyle is deeply disturbing. Everyone
makes a mistake sometime. That is ordinary, and human, and very
forgivable. But to make the same mistake year after year. That's not.
That's extraordinary.</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"></span><br /></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"><strong>SCREENING FOR ALCOHOL MISUSE: THE NEW USPSTF RECOMMENDATION: </strong>The Task Force has been very busy. In this <a data-cke-saved-href="http://www.uspreventiveservicestaskforce.org/draftrec.htm" href="http://www.blogger.com/blogger.g?blogID=340176576888120508">updated recommendation</a> they confirm their previous 2004 recommendation: "The USPSTF
recommends that clinicians screen adults, including young adults and
pregnant women, for alcohol misuse and provide persons engaged in risky
or hazardous drinking with brief behavioral counseling interventions to
reduce alcohol misuse."</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">In the related <a data-cke-saved-href="http://annals.org/article.aspx?articleid=1361859" href="http://www.blogger.com/blogger.g?blogID=340176576888120508">systematic review</a> in Annals of Internal Medicine</span><span style="font-family: trebuchet ms,helvetica,sans-serif;"> the Task Force summarizes the evidence for this recommendation as follows:</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">"The 23 included trials generally excluded persons with alcohol dependence. The best evidence was for brief (10- to 15-minute) multicontact interventions. ['Very brief single contact (e.g., </span><strong><u><</u></strong> <span style="font-family: trebuchet ms,helvetica,sans-serif;">5 minutes) has limited impact.'] </span><span style="font-family: trebuchet ms,helvetica,sans-serif;">Among adults receiving behavioral interventions, consumption decreased by 3.6 drinks per week from baseline; 12% fewer
adults reported heavy drinking episodes; and 11% more adults reported
drinking less than the recommended limits. Evidence was insufficient to
draw conclusions about accidents, injuries, or alcohol-related liver
problems. Trials enrolling young adults or college students showed
reduced consumptions and fewer heavy drinking episodes."</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"><strong>COMMENT</strong>:
While we can all agree that moderate alcohol use is important to a
healthy lifestyle, it is difficult to see why it is rated as more
important th</span><span style="font-family: trebuchet ms,helvetica,sans-serif;">an nutrition [actually an alcohol intervention ought to be considered a component of a global nutritional intervention] or exercise counseling. The reason for the difference in recommendations appears to be that the USPSTF considers alcohol counseling to be worth a more intense intervention (brief multicontact
[each contact is 6-15 minutes) whereas it concludes that nutrition and
exercise counseling only merit brief intervention counseling, which is
ineffective according to their data, just as it is ineffective for
alcohol counseling. Why the USPSTF is now willing to endorse 'brief multicontact interventions of 6-15 minutes for nutrition
and exercise counseling is a mystery. Furthermore, the results cited in
their evidence summary for the alcohol intervention involves only
intermediate outcomes (i.e., the amount of alcohol consumed); the
evidence is not adequate to demonstrate improved outcomes that
matter--reduced accidents, lost time from work, less cirrhosis, etc.</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">Certainly the poster above for lifestyle counseling shows far more significant improvements</span><span style="font-family: trebuchet ms,helvetica,sans-serif;"> in outcomes that matter (incidence of major chronic diseases, cancer, and overall mortality).</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">The USPSTF appears to have some kind of bias against nutrition and exercise counseling that is not explained by the evidence. Go figure.</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"><strong>OTHER FACTORS YOU MIGHT WANT TO CONSIDER:</strong></span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"><strong>1. Sunscreen is expensive: </strong>These
investigators performed a cost analysis study of sunscreen needs in two
scenarios: a family of four on a 1-week beach vacation (4 hours/day in
the sun), females in bikinis, males in swim trunks, reapplying sunscreen
twice for adults and 3 times for children, and no other sun-protective
measures taken), and a transplant patients using sunscreen year round.
They also evaluated costs of 607 sunscreens from 17 Internet drugstores
in 7 countries. Median sunscreen price was $1.70 per 10 g. Assuming that
standard sunscreen application recommendations (2 mg/cm2) were
followed, the median cost to the family varied from 4178.20 per week (if
children were 2-year olds) to $238.40 per week (if children were 10-year-olds).
The cost decreased by 33% if the family wore UV-protective T-shirts and
by 41% if large-volume bottles were used--both strategies combined
reduced the costs by 58%. The median cost to a transplant patients
vai3ed from $245 to 292 per year.(6)</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"><strong>2. Lifestyle changes could prevent 50% of common cancers: </strong></span><span style="font-family: trebuchet ms,helvetica,sans-serif;">A research presenting at the Union for International Cancer Control (UICC)
World Cancer Congress 2012 states: "More than 50% of cancer could be
prevented if people simply implemented what is already known about
cancer prevention." Most of this derives from lifestyle interventions.
While the 'biggest buy' from lifestyle</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">intervention
is smoking cessation. It is also estimated that being overweight or
obese causes approximately 20% of cancer. If people could maintain a
healthy body mass index, the incidence of cancer could be reduced by
approximately 50% in 2 to 20 years. (A healthy BMI for cancer prevention
is from 21 to 23 kg/m2. Poor diet and lack of exercise are each
associated with about 5% of all cancers. Improvement in diet could
reduce cancer incidence by 50% and increases in physical activity could
reduce cancer incidence by as much as 85% in 5 to 20 years.(7) COMMENT</span>: <span style="font-family: trebuchet ms,helvetica,sans-serif;">Nonetheless the USPSTF
remains far more interested in expensive and inconvenient screening
strategies like mammography, occult blood stool testing, and colonoscopy
to reduce breast cancer and colon cancer, respectively, by a mere 15%.
The evidence is good, the impact and cost:benefit ratios, however, are
disappointing.</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;"><strong>3. An alternative approach to obesity--prevention: </strong>The Institute of Medicine (supported by he Robert Wood Johnson Foundation) has issued a report on the prevention of obesity.(8)</span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">"Obesity
has become so pervasive and severe that it 'constitutes a startling
setback to major improvements achieved in other areas of health during
the past century.'...What the country needs now is a set of obesity
prevention action that, both individually and together, can accelerate
meaningful change on a societal level." The Committee's recommendations
include aggressive promotion of physical activity [Take note, USPSTF!], creation of environments conducive to healthy eating, and expanding the role of health care
providers, employers, and schools in obesity prevention. The report
identified 5 critical areas, or 'environments,' from which to attack the
problem: physical activity, food and beverage, message (or marketing), health care and work, and schools. The 5 major goals for these environments are:</span></div>
<ol>
<li class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: trebuchet ms,helvetica,sans-serif;">To make physical activity an integral and routine part of daily life.</span></li>
<li class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: trebuchet ms,helvetica,sans-serif;">To create food and beverage 'environments' that ensure that healthy options are routine and easy choices.</span></li>
<li class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: trebuchet ms,helvetica,sans-serif;">To transform messages about physical activity and nutrition.</span></li>
<li class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: trebuchet ms,helvetica,sans-serif;">To expand the role of health care providers, insurers, and employers in obesity prevention.</span></li>
<li class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: trebuchet ms,helvetica,sans-serif;">To make schools a national focal point for the prevention of obesity.</span></li>
</ol>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">Specifically, with respect to health care providers, they recommend:</span></div>
<ul>
<li class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: trebuchet ms,helvetica,sans-serif;">Health care
providers' standards of practice should include routine body mass index
screening, counseling, and behavioral interventions for children,
adolescents, and adults to improve physical activity behaviors and
dietary choices.</span></li>
<li class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: trebuchet ms,helvetica,sans-serif;">Medical, nursing, and physician assistants schools, and other relevant health care
professional training programs and continuing education should include
instruction in prevention, screening, diagnosis, and treatment of
overweight and obesity in children, adolescents, and adults.</span></li>
<li class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: trebuchet ms,helvetica,sans-serif;">Health care providers should serve as role models for their patients.</span></li>
</ul>
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<span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><strong><span style="color: #660033; font-family: Verdana;">parts per million of atmospheric carbon compatible with a familiar, sustainable planet Earth</span></strong></span></span></div>
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<span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><strong><u>REFERENCES</u></strong>:</span></span> </span></span></div>
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<span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"> </span></span></span></span></div>
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<span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;">1. </span></span></span></span><span style="font-family: trebuchet ms,helvetica,sans-serif;">Lin JS, Eder M, Weinmann
S. Behavioral counseling to prevent skin cancer: A systematic review
for the US Preventive Services Task Force. Ann Intern Med 2011; 154:
190-201. Guideline: </span><a data-cke-saved-href="http://www.uspreventiveservicestaskforce.org/uspstf11/skincancouns/skincancounsrs.htm" href="http://www.uspreventiveservicestaskforce.org/uspstf11/skincancouns/skincancounsrs.htm"><span style="font-family: trebuchet ms,helvetica,sans-serif;">http://www.uspreventiveservicestaskforce.org/uspstf11/skincancouns/skincancounsrs.htm</span></a></div>
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<span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;">2.</span></span> <span style="font-family: trebuchet ms,helvetica,sans-serif;">Moyer
VA. Behavioral counseling interventions to promote a healthful diet and
physical activity for cardiovascular disease prevention in adults: US
Preventive Services Task Force Recommendation Statement. Ann Intern Med
2012; 157: 367-72.</span></div>
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<span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;">3. </span></span><span style="font-family: trebuchet ms,helvetica,sans-serif;">Moyer
VA. Screening for and management of obesity in adults: US Preventive
Services Task Force Recommendation Statement. Ann Intern Med 2012; 157:
373-8.</span></div>
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<span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;">4. Journal Watch 2004; 24 No 2: 18; cited in Action Advisor for Primary Care 2004; Vol 6 No 1: 3.</span></span></div>
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<span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;">5. Little P. GP documentation of obesity: What does it achieve? Br J Gen Pract 1998; 48: 890-4; abstracted in The Family Practice Newsletter 1998; Vol 13 No 6: 24.</span></span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">6. Mahe E et al. Are sunscreens luxury products? J Am Acad Dermatol 2011 Jul 11; [e-pub ahead of print]; http://dx.doi.org/10.1016/j.jaad.2010.06.043; abstracted in Journal Watch 2011.</span></div>
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">7. Harrison P. Lifestyle changes could prevent 5<span style="font-family: trebuchet ms,helvetica,sans-serif;">0%
of common cancers. September 5, 2012 (Montreal, Quebec). Union of
International Cancer Control (UICC) World Cancer Congress 2012.
Presented August 29, 2012; reported in Medscape Medical News 2012: </span><a data-cke-saved-href="http://www.medscape.com/viewarticle/770357" href="http://www.medscape.com/viewarticle/770357"><span style="font-family: trebuchet ms,helvetica,sans-serif;">http://www.medscape.com/viewarticle/770357</span></a></span><div align="left" class="MsoNormal" style="margin: 0in 0in 0pt;">
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<span style="font-family: trebuchet ms,helvetica,sans-serif;">8. Institute of Medicine. Accelerating progress in obesity prevention: Solving the weight of the nation. </span><a data-cke-saved-href="http://www.medscape.org/viewarticle/763753" href="http://www.medscape.org/viewarticle/763753"><span style="font-family: trebuchet ms,helvetica,sans-serif;">http://www.medscape.org/viewarticle/763753</span></a></div>
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Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com1tag:blogger.com,1999:blog-340176576888120508.post-34300474715267774462012-06-22T14:40:00.001-07:002012-06-22T14:40:41.526-07:00MORE SUPPORT FOR A HEALTHY LIFESTYLE (DID WE NEED ANY?)<div style="text-align: center;"><span style="font-family: "Trebuchet MS", sans-serif;"><strong>A VIEW FROM THE OFFI CE</strong></span></div><div style="text-align: center;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><a href="http://2.bp.blogspot.com/-04Gqn7WoXj8/TTaERYtLVWI/AAAAAAAAABw/0hmJffUi0SM/s1600/Portola1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: "Trebuchet MS", sans-serif;"><strong><img border="0" height="240" rca="true" src="http://2.bp.blogspot.com/-04Gqn7WoXj8/TTaERYtLVWI/AAAAAAAAABw/0hmJffUi0SM/s320/Portola1.jpg" width="320" /></strong></span></a></div><div class="separator" style="clear: both; text-align: center;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><span style="color: #060b6b;"><span style="font-family: Trebuchet MS;"><b>MORE SUPPORT FOR A HEALTHY LIFESTYLE</b></span></span></div><div align="center" class="MsoNormal" style="margin: 0in 0in 0pt;"></div><div align="center" class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="color: #060b6b;"><b style="font-family: "Trebuchet MS";">(DID WE NEED ANY?)</b></span></div><div align="center" class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="color: #060b6b;"><strong><span style="font-family: Trebuchet MS;"></span></strong></span> </div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgt-B5ZHBU6K32-ypo-5lnC-ui6hdc3RZd4nCd8DGMm2ecgSZ4oB1oGH52kxi46HleILvuHU3jH-HKsoWfwwRYxXAMe6G6vGPXSs3Sl7i7vUJUNSrInns-SdqSSkvRG93UJ1DKBw-j34z4/s1600/EPHC+Lifestyle+poster+2-sided%255B1%255D_Page_2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="640" rca="true" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgt-B5ZHBU6K32-ypo-5lnC-ui6hdc3RZd4nCd8DGMm2ecgSZ4oB1oGH52kxi46HleILvuHU3jH-HKsoWfwwRYxXAMe6G6vGPXSs3Sl7i7vUJUNSrInns-SdqSSkvRG93UJ1DKBw-j34z4/s640/EPHC+Lifestyle+poster+2-sided%255B1%255D_Page_2.jpg" width="484" /></a></div><div align="center" class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="color: #060b6b;"><strong><span style="font-family: Trebuchet MS;"></span></strong></span> </div><div align="center" class="MsoNormal" style="margin: 0in 0in 0pt;"></div><div class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><b style="font-family: "Trebuchet MS"; text-align: left;"><u><span style="color: #060b6b;">LIFESTYLE RISK FACTORS PREDICT DISABILITY AND DEATH IN HEALTHY AGING ADULTS [THE 15TH MAJOR LIFESTYLE STUDY]</span></u>: </b><span style="font-family: "trebuchet ms", helvetica, sans-serif;"><span>For the development of my "<strong><span style="color: #116600;">Formula for Health</span></strong>" I had collected 13 major observational studies and 1 RCT to support the synthesis of lifestyle essentials into just 5 lifestyle factors. These were cited in my </span></span><a data-cke-saved-href="http://www.aafp.org/afp/2010/0915/p610.html" href="http://www.aafp.org/afp/2010/0915/p610.html" style="font-family: "trebuchet ms", helvetica, sans-serif;"><span>Editorial</span></a><span><span style="font-family: "trebuchet ms", helvetica, sans-serif;"> in </span><em style="font-family: "trebuchet ms", helvetica, sans-serif;"><strong>American Family Physician </strong></em><span style="font-family: "trebuchet ms", helvetica, sans-serif;">in 2010. Now it is time to add a new observational study to the list.(1)</span></span></div><div class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span style="font-family: trebuchet ms, helvetica, sans-serif;"><span> "[The] [p]ositive health effects of maintenance of normal weight, routine exercise, and nonsmoking are known for the short and intermediate term." These investigators studied the effects of these risk factors into advanced age. They collected data from 2,327 college alumnae aged 60 years of more who were followed annually (1986-2005) by questionnaires addressing health risk factors, history, and Health Assessment Questionnaire disability. Mortality data were ascertained from the National Death Index. Low-, medium-, and high-risk groups were created on the basis of the number (0, 1, <u>></u> 2) of health risk factors (overweight, smoking, inactivity) at baseline. The medium- and high-risk groups had higher disability than the low-risk group throughout the study (P , 0.001). <strong><span style="color: #060b6b;">Low-risk subjects had onset of moderate disability delayed 8.3 years compared with high-risk subjects</span></strong>. <span style="color: #ba0f2b;"><strong>Mortality rates were higher in the high-risk group (384 vs 247 per 10,000 person-years)</strong></span>. The authors conclude: "Seniors with fewer behavioral risk factors during middle age have lower disability and improved survival. These data document that the associations of lifestyle risk factors on health continue into the ninth decade." </span></span></div><div class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span style="font-family: trebuchet ms, helvetica, sans-serif;"><span>COMMENT: We already knew this, at least for elderly Europeans (aged 70-95 years) from <strong>the HALE Study</strong> which looked at 4 factors (not smoking, Mediterranean diet, exercise, and some consumption of alcohol. The benefits observed in </span><a data-cke-saved-href="http://jama.jamanetwork.com/article.aspx?articleid=199485" href="http://jama.jamanetwork.com/article.aspx?articleid=199485"><span>the HALE study</span></a><span> were truly dramatic-- 61-64% reductions in coronary and peripheral vascular mortality, 36% reductions in cancer (of all causes), and a 60% reduction in all-cause mortality. [It's OK to gasp.]</span></span></div><div class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"> <span style="font-family: trebuchet ms, helvetica, sans-serif;"><span>So how much more data will it take before something like the "<strong><span style="color: #116600;">Formula for Health</span></strong>" becomes the cornerstone of all primary care--from cradle to grave? (Of course, it is NOT a data problem. Those who could be persuaded by data WERE persuaded a long time ago. For the rest, the data are irrelevant. It will probably take until ALL of the MONEY runs out to pay for procedures, tests, and medications before we give primary prevention a chance.</span></span></div><div class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span></span></div><div class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span><u><span style="color: #060b6b;"><b>REVIEWING THE "FORMULA FOR HEALTH": DOES ADVICE TO EXERCISE WORK?</b></span></u><span style="font-family: trebuchet ms, helvetica, sans-serif;"> Of course, it does, but it's hard to prove. For this reason the USPSTF has dismissed physician counseling for exercise to the trash bin of "<a data-cke-saved-href="http://www.uspreventiveservicestaskforce.org/3rduspstf/physactivity/physactrr.htm" href="http://www.uspreventiveservicestaskforce.org/3rduspstf/physactivity/physactrr.htm">insufficient evidence</a>," which I have always considered unfair. <span style="font-size: 16px;">"</span></span><span style="font-size: 16px;"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-family: "trebuchet ms", helvetica, sans-serif;"><span style="color: #060b6b;"><em>The USPSTF found insufficient evidence to determine whether counseling patients in primary care settings to promote physical activity leads to sustained increases in physical activity among adult patients. Controlled trials of physical activity counseling in adult primary care patients were of variable quality and had mixed results. There were no completed trials with children or adolescents that compared counseling with usual care practices</em></span>."</span> [Not updated since 2002] </span></span><span style="font-family: "trebuchet ms", helvetica, sans-serif;">While we have to make concessions to the fact that the studies are few, small, often uncontrolled, and generally use suspicious "self-reported" amounts of exercise as outcomes, the remarkable thing is that a few minutes of physician or practice time, whether face-to-face or by phone or by class, makes a difference; the trend among studies is phenomenal. And, all of the lifestyle studies with their more global perspective identify exercise as a key component of a healthy lifestyle that is associated with the dramatic improvements in outcomes as mentioned above.</span></span></div><div class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"> <span><span style="font-family: trebuchet ms, helvetica, sans-serif;">The British are far more pragmatic and ultimately more fair, and with good reason. The BMJ has just published a <strong><span style="color: #060b6b;">systematic review of physical activity promotion based in primary care</span></strong> and found that <strong><span style="color: #060b6b;">it significantly increases physical activity levels at 12 months</span></strong>.(2) A prior meta-analysis of cohort studies found that <strong><span style="color: #060b6b;">self reported achievement of the official UK exercise goal (150 minutes of moderate intensity activity each week) was associated with a 19% reduction in the rate of all cause mortality</span></strong>, compared with sedentary behavior.(3) </span><span style="font-family: "trebuchet ms", helvetica, sans-serif;">In the UK only 39% of men and 29% of women achieve this goal (2008).</span><span style="font-family: "trebuchet ms", helvetica, sans-serif;"> </span><strong style="font-family: "trebuchet ms", helvetica, sans-serif;"><span style="color: #060b6b;">A Cochrane review of interventions to promote physical activity in community dwelling adults showed a moderate effect on self reported physical activity and cardiorespiratory fitness at a minimum of 6 months of follow-up</span></strong><span style="font-family: "trebuchet ms", helvetica, sans-serif;">. In addition, similar brief interventions have previously been shown to reduce smoking and alcohol use. One of the major problems with previous studies on exercise are that reviews included non-randomized trials and trials with short follow-up duration. Since the USPSTF recommendation (2002), however, there have been several large trials of physical activity promotion based in primary care with outcomes data after at least 12 months. It is time to take a fresh look. [Shame on you, USPSTF!]</span></span></div><div class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"> <span style="font-family: trebuchet ms, helvetica, sans-serif;"><span>These investigators found a total of <strong>15 relevant randomized controlled trials</strong> with 8745 subjects. Most interventions took place in primary care, included health professionals in delivery, and involved advice or counseling given fact to face or by phone (or both) on multiple occasions. <strong><span style="color: #060b6b;">In the 13 trials presenting self-reported physical activity, there were small to medium positive intervention effects as 12 months (OR, 1.42).</span></strong> The <strong><span style="color: #060b6b;">number-needed-to treat for one additional sedentary adult to meet internationally recommended levels of activity as only 12</span></strong> (7-33). These are very positive results.</span></span></div><div class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"> <span style="font-family: trebuchet ms, helvetica, sans-serif;"><span>Here are some other noteworthy aspects of the data to consider:</span></span></div><ol><li class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span style="font-family: trebuchet ms, helvetica, sans-serif;"><span>The authors could find no unpublished studies on brief interventions to promote exercise. Funnel plots of their pooled data did not suggest any publication bias.</span></span></li>
<li class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span><span style="font-family: "trebuchet ms", helvetica, sans-serif;">A planned subgroup analysis showed significantly larger intervention effects on self reported activity in studies where control participants received no intervention than where they received a lesser comparator intervention. <strong><span style="color: #060b6b;">This analysis suggests that the observed positive effect on exercise levels may be underestimated as it appears that the comparator interventions themselves had positive effects</span></strong>. "The additional percentage of participants who reported meeting international activity recommendations at 12 months, compared with baseline, was 11-47% in participants allocated to receive an intervention, and 8-47% in those allocated to receive a comparator intervention. The corresponding range for those allocated to receive no intervention was from -2% to +19%. <strong><span style="color: #060b6b;">These findings suggest that briefer interventions, as used in the comparator groups, might achieve effects that are similar to those of more intensive interventions</span></strong>."</span><span style="font-family: "trebuchet ms", helvetica, sans-serif;"> </span></span></li>
<li class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span style="font-family: "trebuchet ms", helvetica, sans-serif;"><span>Only one study reported an objective measure of physical activity level as an outcome, and in this study it was not significantly different. The authors call for more studies with an objective measure of outcome.</span></span></li>
<li class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span style="font-family: "trebuchet ms", helvetica, sans-serif;"><span>Only one study found a significant intervention effect on adverse events, reporting a relative 11% increase in falls and a 6% increase in injuries among intervention participants.</span></span></li>
<li class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span><span style="font-family: "trebuchet ms", helvetica, sans-serif;">Since follow-up was limited to only 12 months in most trials, the effect of the exercise intervention of diabetes, cardiovascular events, or mortality could not be assessed. </span><span style="font-family: "trebuchet ms", helvetica, sans-serif;"> </span></span></li>
</ol><div class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span style="font-family: trebuchet ms, helvetica, sans-serif;"><span><strong>COMMENT:</strong> The USPSTF has been way too timid. They are missing the forest for the trees. Promoting exercise should be consider one of the absolute core activities of primary care practice. It's not. The USPSTF could be helping. It is not.</span></span></div><div class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span></span></div><div class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span><strong><span style="font-family: trebuchet ms, helvetica, sans-serif;"><u><span style="color: #060b6b;">WALKING TO SAVE YOUR MIND</span></u>: </span></strong><span style="font-family: trebuchet ms, helvetica, sans-serif;">The Japanese have conducted a trial to evaluate the efficacy of a municipality-led walking program under the Japanese public Long-Term Care Insurance Act to prevent mental decline.(4) These data are from the program in the city of Takasaki. One hundred fifty community members aged 72.0 =/- 4 were randomly divided into intervention and control groups. <span style="color: #060b6b;"><strong>A walking program was conducted once a week for 90 minutes for 3 months</strong></span>. The program encouraged participants to walk on a regular basis and to increase their steps per day gradually. The intervention was conducted in small groups of approximately six in order to obtain possible benefits in both exercise and social interaction. Cognitive function was measured using 9 tests in 5 domains: memory, executive function, word fluency, visuospatial abilities, and sustained attention. Quality of life, depressive state, functional capacity, range of activities, and social network were also assessed as well as motor function. <strong><span style="color: #060b6b;">There were significant differences between the intervention and control group in word fluency related to frontal lobe function (P=0.01), quality of life (P=0.002), functional capacity including social interaction (P < 0.001), and motor function (Timed Up and Go Test; P=0.002)</span></strong>. <strong>COMMENT</strong>: As opposed to the "do nothing" attitude of the USPSTF, this is the kind of program we should be starting in our practices. Get every staff member (including a stint for yourself!) to lead a group at different hours during the day. I had a resident a few years ago (my esteemed Chief Resident at Santa Rosa, Dr. Serena Brewer, Touro graduate) who designed a project to do just this in a residency clinic setting. It would even reimburse well (if a provider spent some face-to-face time with each patient). You know what doomed it in this setting? The supporting hospital's fears of potential legal liability in the case that a patient might slip and fall. Sigh. We have to do better than this.</span></span></div><div class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span></span></div><div class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span style="font-family: trebuchet ms, helvetica, sans-serif;"><span><u><strong><span style="color: #060b6b;">HOW OFTEN SHOULD I EXERCISE, DOC?</span> </strong></u><span style="font-family: trebuchet ms, helvetica, sans-serif;">The answer from Joseph Alpert, MD [Editor-in-Chief of American Journal of Medicine] is "Only on the days you eat."(8) His full answer is: "Our DNA heritage with its highly complex biochemical and physicological processes is appropriate to a very active lifestyle, not a modern 21st centruy couch potato, fast-food existence. Consdequently, we should make every effort to include elements that resemble the Paleolithic lifestyle [of our ancestors] in our modern daily existence. My lifestyle includes daily exercise, lots of fruits and vegetables in the diet, and avoidance of heavily engineered snack food. Of course, I also do not smoke tobacco nor do I consume large quantities of alcohol. I recommend these liefstyle elements to all my patients. When friends or family ask, 'How often should I exercise?' my answer is always 'Only on the days you eat.' That seems to get the message across." COMMENT: It's a shame that he didn't mention relaxation or stress reduction. But perhaps that is not an option for the Editor in Chief of American Journal of Medicine. </span></span></span></div><div class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span></span></div><div class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span style="font-family: trebuchet ms, helvetica, sans-serif;"><span><strong><u><span style="color: #060b6b;">ANOTHER ASIAN STUDY: AS LITTLE AS 15 MINUTES OF EXERCISE EACH DAY MAY PROLONG LIFE</span></u>: </strong>A prospective cohort study from Taiwan examined the association between physical activity and mortality.(5) In this study, people who did as little as 90 minutes of exercise each week (who would ordinarily be considered physically inactive) were analyzed as a separate group. Around 12.5% (28,311 of 226,493 subjects) of those who exercised at all did so for about 15 minutes of 6 days a week. The study followed up for an average of 8 years more than 400,000 people who underwent regular health check-ups. <strong><span style="color: #ba0f2b;">Compared with people who exercised very little, those who did not exercise at all had a 17% higher risk of dying from any causes, and an 11% higher risk of dying from cancer</span></strong>. <strong><span style="color: #060b6b;">Each extra 15 minutes of daily exercise was linked with a 4% reduction in the risk of dying from any cause, and a 1% lower risk of cancer related death.</span></strong> The results held in both sexes, regardless of age, smoking and drinking habits, and overall risk of cardiovascular disease. The authors conclude that, <strong><span style="color: #060b6b;">at age 30, men who exercised for 15 minutes each day on average could expect to live 2.6 years longer than their peers who did not exercise at all; women could expect 3.1 years of extra life. Among 30 year olds who met the recommendations for physical activity--30 minutes exercise on 5 days a week--men could expect to live 4.2 years longer and women 3.7 years longer</span></strong>, compared with their physically inactive peers.</span></span></div><div class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><br />
</div><div align="left" class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;"><span style="font-family: Trebuchet MS;">1. </span></span> Chakravarty EF et al. Lifestyle risk factors predict disability and death in healthy aging adults. Am J Med 2012; 125: 190-197.</span></span></div><div align="left" class="MsoNormal" style="margin: 0in 0in 0pt;"></div><div align="left" class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: "Trebuchet MS";">2. Orrow G. et al. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ 2012; 344:e1389 doi: 10.1136/bmj.e1389 (March 26, 2012).</span></div><div align="left" class="MsoNormal" style="margin: 0in 0in 0pt;"></div><div align="left" class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: "Trebuchet MS";">3. Woodcock J et al. Non-vigorous physical activity and all-cause mortality: systematic review and meta-analysis of cohort studies. Int J Epidemiol 2011; 40: 121-38.</span></div><div align="left" class="MsoNormal" style="margin: 0in 0in 0pt;"></div><div align="left" class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: "Trebuchet MS";">4. Maki Y et al. Effects of an intervention using a community-based walking program for prevention of mental decline: a randomized controlled trial. J Am Geriatr Soc 2012 Mar; 60(3): 505-10. doi: 10.1111/j.15</span></div><div align="left" class="MsoNormal" style="margin: 0in 0in 0pt;"></div><div align="left" class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: "Trebuchet MS";">5. Wen CP et al. Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study. <a data-cke-saved-href="http://www.sciencedirect.com/science/article/pii/S0140673611607496" href="http://www.sciencedirect.com/science/article/pii/S0140673611607496">Lancet 2011; 378: 1244-53</a>.</span></div>Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com4tag:blogger.com,1999:blog-340176576888120508.post-73937392092851206892012-06-12T15:28:00.002-07:002012-06-14T18:51:30.966-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
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<b><span style="font-family: 'Trebuchet MS',sans-serif;">A COCKTAIL FOR LONGEVITY & HEALTH</span></b></div>
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<b><span style="font-family: 'Trebuchet MS',sans-serif;">A VIEW FROM THE OFFICE</span></b></div>
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<span style="font-family: 'Trebuchet MS';"><b>DIET & LONGEVITY: A NEW APPROACH</b></span></div>
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<b style="font-family: 'Trebuchet MS';">GLASSES UP! A COCKTAIL TO ROUND UP YOUR LIFE: </b><span style="font-family: 'trebuchet ms',helvetica,sans-serif;">As you know (perhaps ad nauseam) my approach to maximizing the lifespan (i.e., reducing all-cause mortality) is to follow The Formula for Health: 0 cigarettes, 5 servings of fruits & vegetables a day, 10 minutes of relaxation a day, maintaining a BMI < 30, and getting 150 minutes of exercise each week. Now these researchers have done me one better. They offer a cocktail of 30 ingredients to delay aging and extend the life span.(1) The data are preliminary but very positive (i.e., in mice). The thesis makes perfect sense. We have learned that health is always multifactorial and never attributable to a single factor. The reason that the Okinawans live so long is that there diet has little meat but contains more than 15 different kinds of fruits and vegetables each day. These investigators have further refined the nutrition essentials to go beyond a simple one-a-day multivitamin (which, prior to this I enthusiastically supported).</span></div>
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<span style="font-family: 'trebuchet ms',helvetica,sans-serif;"></span> <span style="font-family: 'trebuchet ms',helvetica,sans-serif;">This nutrient cocktail was developed by Dr. C. David Rollo and colleagues at the McMaster University in Canada. It was not a simple ad hoc formulation, but was strategically selected to address the five key mechanisms of aging. </span></div>
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<span style="font-family: 'trebuchet ms',helvetica,sans-serif;"><b>THE 5 KEY MECHANISMS OF AGING</b></span></div>
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<span style="font-family: 'trebuchet ms',helvetica,sans-serif;">oxidative stress</span></div>
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<span style="font-family: 'trebuchet ms',helvetica,sans-serif;">inflammation</span></div>
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<span style="font-family: 'trebuchet ms',helvetica,sans-serif;">mitochondrial dysfunction</span></div>
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<span style="font-family: 'trebuchet ms',helvetica,sans-serif;">insulin resistance</span></div>
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<span style="font-family: 'trebuchet ms',helvetica,sans-serif;">loss of membrane integrity</span></div>
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<b style="font-family: 'Trebuchet MS';"></b><span style="font-family: 'Trebuchet MS';">"No single mechanism alone accounts for any one specific disease process. Instead, all five mechanisms interact with one another to produce both general aging and specific conditions that limit activity, cognitive function, and ultimately lifespan...All animals, from worms to insects to humans, change in very similar fashions as they succumb to the five key mechanisms of aging." Dr. Rollo and colleagues studied the impact of these nutrients on laboratory mice because of their short normal life span." (A mouse is considered 'old' by age 2 years.) They sought to study measures that would apply equally to mice and humans. They chose to focus on how much the aging animals moved and how their cognitive function changed with time. </span></div>
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<span style="font-family: 'Trebuchet MS';"></span> "<span style="font-family: 'trebuchet ms',helvetica,sans-serif;">As they grow older, all animal species move about less and less each day, spending more and more time at rest or in sleep. Reduced mobility is an excellent marker of aging, because it is closely linked to overall metabolic rate, feeding, fat storage, brain neurotransmitter levels, mitochondrial function, and cardiovascular and skeletal muscle systems...[L]loss of mobility in humans is associated with muscle wasting, bone thinning, and other changes that increase the risk of other negative outcomes such as fractures, pneumonia, and skin infections. Cognitive function also declines with age in all animal populations. Younger animals typically learn faster, requiring fewer repetitions to master a task. They can also bring up important memories faster and more accurately, allowing them to find food, escape threats, and protect other members of their species. Studies show that preserving cognitive function into older ages is associated with longer life spans."</span></div>
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<span style="font-family: 'trebuchet ms',helvetica,sans-serif;"> </span> <span style="font-family: 'trebuchet ms',helvetica,sans-serif;">In the study, the 30-ingredient cocktail was soaked into small pieces of bagel. For the longevity study they used both normal mice and a special strain that demonstrates accelerated aging as a result of excessive sensitivity to all five aging mechanisms. Compared with control animals, the supplemented mice of the accelerated aging strain lived 28% longer. Supplemented normal mice survived 11% longer than controls. For the mobility component of the study the investigators placed the mice in a system of transparent chambers, where they were given food, water, and an exercise wheel; they recorded the amount of time each animal spent moving about the enclosure over a 24-hour period. "Normal, unsupplemented mice showed a progressive decline in activity; by 24 months their mobility was roughly half that of younger normal animals. By 24 months of age, supplemented normal mice were moving roughly three hours more per day than were unsupplemented animals. No other treatment has ever been found that ameliorates declining mobility to this extent."</span></div>
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<span style="font-family: 'trebuchet ms',helvetica,sans-serif;"></span> <span style="font-family: 'trebuchet ms',helvetica,sans-serif;">Dr. Rollo's group also measured biochemical markers that might explain the difference in mobility. Supplemented older mice had increased activity of the neurotransmitter dopamine (decreased dopamine levels are associated with loss of movement in aging humans and in Parkinson's disease). They also had increased measures of mitochondrial activity, "suggesting that supplemented animals simply had more energy as they aged." Finally, they measured decreased levels of protein corbonyls--altered molecules that reflect the impact of glycation and oxidation on cells and tissues.</span></div>
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<span style="font-family: 'trebuchet ms',helvetica,sans-serif;"></span> <span style="font-family: 'trebuchet ms',helvetica,sans-serif;">To assess cognitive outcomes they tested the mice on a water maze that required the animals to find and remember the location of a platform submerged just below the surface of a pool filled with waters. This test is an indicator of both learning skills and memory. They repeated this test each day for 5 days. At first all of the animals had difficulty finding the platform taking an average of 81 seconds. By day 5 young mice had learned and remembered enough to find the platform 43% faster than on day 1. "Older unsupplemented mice, however, showed no significant improvement in the time it took them to find the platform, indicating age-related impairments in learning and memory. But with supplementation, old mice showed a level of learning almost identical to that of young mice; in fact on day 5 they took an average of 46% less time to find the platform than they did on day 1. In other words, supplemented old mice showed the same ability to learn and remember new tasks as did young animals." In the related biochemical observations they noted that brain mitochondrial activity fell steadily with age in the untreated mice, while supplemented animals showed a steady increase in this measure of brain energy supply; mice with higher brain mitochondrial activity proved to be significantly better learners than those with lower mitochondrial activity; and brain weights, which normal decrease with age, were higher in supplemented male mice by 7%, and in females by 11%, compared with brain weights of control animals.</span></div>
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<span style="font-family: 'trebuchet ms',helvetica,sans-serif;"></span> <span style="font-family: 'trebuchet ms',helvetica,sans-serif;">The editors of Life Extension Magazine (free 3 month trial subscription available at this link: </span><span style="font-family: arial,helvetica,sans-serif;"><a data-cke-saved-href="http://www.lef.org/magazine/mag2012/may2012_Nutrient-Cocktail-Delays-Aging-Extends-Life-Span_01.htm" href="http://www.lef.org/magazine/mag2012/may2012_Nutrient-Cocktail-Delays-Aging-Extends-Life-Span_01.htm">http://www.lef.org/magazine/mag2012/may2012_Nutrient-Cocktail-Delays-Aging-Extends-Life-Span_01.htm</a>) summarize the article as follows:</span></div>
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<ol>
<li class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span style="font-family: arial,helvetica,sans-serif;"><span style="font-family: 'trebuchet ms',helvetica,sans-serif;">"Aging is a complex, multifactorial process, but five major mechanisms are now known to account entirely or in part for most human age-related diseases.</span></span></li>
<li class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span style="font-family: arial,helvetica,sans-serif;"><span style="font-family: 'trebuchet ms',helvetica,sans-serif;">Dr. Rollo and colleagues have developed and tested successfully in mice a 30-nutrient supplement mixture designed to attack all 5 mechanisms of aging.</span></span></li>
<li class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span style="font-family: arial,helvetica,sans-serif;"><span style="font-family: 'trebuchet ms',helvetica,sans-serif;">Tested in mice, the supplement mix extends life span by up to 28% while improving the aging animals' mobility and cognitive function.</span></span></li>
<li class="MsoNormal" style="margin: 0in 0in 0pt; text-align: left;"><span style="font-family: arial,helvetica,sans-serif;"><span style="font-family: 'trebuchet ms',helvetica,sans-serif;">All 30 ingredients are known to be safe and effective in human beings.</span></span><span style="font-family: 'trebuchet ms',helvetica,sans-serif;">If this mixture, or one like it, has similar effectiveness in humans, one could expect an 80-year-old to add nearly 9 years of life with youthful levels of activity and cognition."</span></li>
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<span style="font-family: 'trebuchet ms',helvetica,sans-serif;">Anyone interested?</span><span style="font-family: 'trebuchet ms',helvetica,sans-serif;"></span></div>
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<span style="font-family: 'trebuchet ms',helvetica,sans-serif;">And, of course, here is the prize. The 30 ingredients of the cocktail are:</span></div>
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<tr><td colspan="6" style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><b>TABLE OF NUTRIENT COCKTAIL INGREDIENTS</b></span></td></tr>
<tr><td style="text-align: center;"><b><span style="font-family: arial,helvetica,sans-serif;">NUTRIENT</span></b></td><td colspan="5" rowspan="1" style="text-align: center;"><b><span style="font-family: arial,helvetica,sans-serif;">MECHANISM OF AGING AFFECTED</span></b></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><b><span style="font-family: arial,helvetica,sans-serif;">Oxidant stress</span></b></td><td style="text-align: center;"><b><span style="font-family: arial,helvetica,sans-serif;">Inflammation</span></b></td><td style="text-align: center;"><b><span style="font-family: arial,helvetica,sans-serif;">Mitochondrial function</span></b></td><td style="text-align: center;"><b><span style="font-family: arial,helvetica,sans-serif;">Insulin resistance</span></b></td><td style="text-align: center;"><b><span style="font-family: arial,helvetica,sans-serif;">membrane integrity</span></b></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">B vitamins (B1, B3 (niacin), B6, B12,and folate.</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">Vitamin C</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">Vitamin D</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">Acetyl-L-carnitine</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">Alpha-lipoic acid</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">Aspirin</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">Beta-carotene</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">Bioflavonoids</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">Chromium picolinate</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td></tr>
<tr><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">Garlic</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td></tr>
<tr><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">Ginger root extract</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">Ginkgo biloba</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td></tr>
<tr><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">Ginseng</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">Green tea extract</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">L-glutathione</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">Magnesium</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">Manganese</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">Melatonin</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">N-acetyl cysteine</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">Potassium </span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">Rutin</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td></tr>
<tr><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">Selenium</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td><td style="text-align: center;"><b><span style="color: #116600;"><span style="font-family: arial,helvetica,sans-serif;">x</span></span></b></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">Vitamin E</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">Cod liver oil (omega-3)</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">Coenzyme Q10</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td></tr>
<tr><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">Flax seed oil</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;"><br /></span></td><td style="text-align: center;"><span style="font-family: arial,helvetica,sans-serif;">x</span></td></tr>
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<span style="font-family: 'Trebuchet MS';"><b>COMMENT</b>: <span style="font-family: 'trebuchet ms',helvetica,sans-serif;">In my opinion this list makes complete sense. Over the years in my newsletters I have reviewed favorably 28 of the 30 ingredients as having important preventive benefits; the only ones that are new to me are rutin and manganese. <b><span style="color: #116600;">The table above suggests particularly potent health benefits from garlic, ginger, selenium, and ginseng</span></b>. </span></span></div>
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<b><span style="color: #080880;"> </span></b><span style="font-family: 'Trebuchet MS';"><span style="font-family: 'trebuchet ms',helvetica,sans-serif;"><b><span style="color: #080880;">One of the important trends in medicine is the evolution of the 'polypill' principal</span></b>. The original 'polypill' published by Wald & Law in the <i>British Medical Journal</i> 2004 consisted of a recommendation for universal consumption, starting at age 50, of an <b><span style="color: #080880;">aspirin, folic acid, a statin, and 3 antihypertensive agents </span></b>(regardless of baseline blood pressure) in half their usual starting doses. The imputed benefits were a <b><span style="color: #080880;">greater than 80% reduction in heart disease and stroke</span></b>. Then came the healthy lifestyle literature starting with <b><span style="color: #080880;">the Hale Study</span></b> focusing on a recipe of <b><span style="color: #080880;">no smoking, regular exercise, a Mediterranean diet</span></b> (which contains a lot of the ingredients above), and any intake of <b><span style="color: #080880;">alcohol</span></b>; the reported benefits for these elderly subjects over 10 years were a <b><span style="color: #080880;">60% reduction in mortality over, a 64% reduction in coronary heart disease, a 61% reduction in cardiovascular disease, and a 60% reduction in cancer</span></b>. On the lifestyle front, I further refined a healthy lifestyle to my <span style="color: #116600;"><b>"Formula for Health"</b></span> with the imputed benefits listed below:</span></span></div>
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<span style="font-family: 'trebuchet ms',helvetica,sans-serif;">This article takes the evolution of this concept yet one more step farther. Expect to see much more of this in the future.</span></div>
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<span style="font-family: 'trebuchet ms',helvetica,sans-serif;"><b>WHAT IS THE BEST WAY TO DISPOSE OF OLD MEDICATIONS? </b>This is an important and very practical concern. The 'experts' have previously led us to believe that to dispose of medications with minimal damage to health and the environment, they should all be dropped off somewhere (like your local pharmacy) to be incinerated. The exception to this was a previous <a data-cke-saved-href="http://Abstral, tablets (sublingual) Fentanyl Actiq, oral transmucosal lozenge * Fentanyl Citrate Avinza, capsules (extended release) Morphine Sulfate Daytrana, transdermal patch system Methylphenidate Demerol, tablets * Meperidine Hydrochloride Demerol, oral solution * Meperidine Hydrochloride Diastat/Diastat AcuDial, rectal gel Diazepam Dilaudid, tablets * Hydromorphone Hydrochloride Dilaudid, oral liquid * Hydromorphone Hydrochloride Dolophine Hydrochloride, tablets * Methadone Hydrochloride Duragesic, patch (extended release) * Fentanyl Embeda, capsules (extended release) Morphine Sulfate; Naltrexone Hydrochloride Exalgo, tablets (extended release) Hydromorphone Hydrochloride Fentora, tablets (buccal) Fentanyl Citrate Kadian, capsules (extended release) Morphine Sulfate Methadone Hydrochloride, oral solution * Methadone Hydrochloride Methadose, tablets * Methadone Hydrochloride Morphine Sulfate, tablets (immediate release) * Morphine Sulfate Morphine Sulfate, oral solution * Morphine Sulfate MS Contin, tablets (extended release) * Morphine Sulfate Nucynta ER, tablets (extended release) Tapentadol Onsolis, soluble film (buccal) Fentanyl Citrate Opana, tablets (immediate release) Oxymorphone Hydrochloride Opana ER, tablets (extended release) Oxymorphone Hydrochloride Oramorph SR, tablets (sustained release) Morphine Sulfate Oxecta, tablets (immediate release) Oxycodone Hydrochloride Oxycodone Hydrochloride, capsules Oxycodone Hydrochloride Oxycodone Hydrochloride, oral solution Oxycodone Hydrochloride Oxycontin, tablets (extended release) * Oxycodone Hydrochloride Percocet, tablets * Acetaminophen; Oxycodone Hydrochloride Percodan, tablets * Aspirin; Oxycodone Hydrochloride Xyrem, oral solution Sodium Oxybate" href="https://app.icontact.com/icp/core/code/message/edit?token=cc6d094067e7a32ac25ffb10337340c6&iMessageId=31434380&sHubId=">FDA recommendation</a> that the following medications could be flushed down the toilet:</span></div>
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<tr><td headers="header1" style="height: 14px;"><b>Abstral</b>, tablets (sublingual)</td><td headers="header2" style="height: 14px;">Fentanyl</td></tr>
<tr><td headers="header1" style="height: 14px;"><b>Actiq</b>, oral transmucosal lozenge <b>*</b></td><td headers="header2" style="height: 14px;">Fentanyl Citrate</td></tr>
<tr><td headers="header1"><b>Avinza</b>, capsules (extended release)</td><td headers="header2">Morphine Sulfate</td></tr>
<tr><td headers="header1" style="height: 12px;"><b>Daytrana</b>, transdermal patch system</td><td headers="header2" style="height: 12px;">Methylphenidate</td></tr>
<tr><td headers="header1" style="height: 22px;"><b>Demerol,</b> tablets <b>*</b></td><td headers="header2" style="height: 22px;">Meperidine Hydrochloride</td></tr>
<tr><td headers="header1"><b>Demerol</b>, oral solution <b>*</b></td><td headers="header2">Meperidine Hydrochloride</td></tr>
<tr><td headers="header1"><b>Diastat/Diastat AcuDial</b>, rectal gel</td><td headers="header2">Diazepam</td></tr>
<tr><td headers="header1"><b>Dilaudid</b>, tablets <b>*</b></td><td headers="header2">Hydromorphone Hydrochloride</td></tr>
<tr><td headers="header1"><b>Dilaudid</b>, oral liquid <b>*</b></td><td headers="header2">Hydromorphone Hydrochloride</td></tr>
<tr><td headers="header1"><b>Dolophine Hydrochloride</b>, tablets <b>*</b></td><td headers="header2">Methadone Hydrochloride</td></tr>
<tr><td headers="header1"><b>Duragesic</b>, patch (extended release) <b>*</b></td><td headers="header2">Fentanyl</td></tr>
<tr><td headers="header1"><b>Embeda</b>, capsules (extended release)</td><td headers="header2">Morphine Sulfate; Naltrexone Hydrochloride</td></tr>
<tr><td><b>Exalgo</b>, tablets (extended release)</td><td>Hydromorphone Hydrochloride</td></tr>
<tr><td headers="header1"><b>Fentora</b>, tablets (buccal)</td><td headers="header2">Fentanyl Citrate</td></tr>
<tr><td headers="header1"><b>Kadian</b>, capsules (extended release)</td><td headers="header2">Morphine Sulfate</td></tr>
<tr><td headers="header1"><b>Methadone Hydrochloride</b>, oral solution <b>*</b></td><td headers="header2">Methadone Hydrochloride</td></tr>
<tr><td headers="header1" style="height: 11px;"><b>Methadose</b>, tablets <b>*</b></td><td headers="header2" style="height: 11px;">Methadone Hydrochloride</td></tr>
<tr><td headers="header1" style="height: 23px;"><b>Morphine Sulfate</b>, tablets (immediate release) <b>*</b></td><td headers="header2" style="height: 23px;">Morphine Sulfate</td></tr>
<tr><td headers="header1"><b>Morphine Sulfate</b>, oral solution <b>*</b></td><td headers="header2">Morphine Sulfate</td></tr>
<tr><td headers="header1"><b>MS Contin</b>, tablets (extended release) <b>*</b></td><td headers="header2">Morphine Sulfate</td></tr>
<tr><td headers="header1"><b>Nucynta ER</b>, tablets (extended release)</td><td headers="header2">Tapentadol</td></tr>
<tr><td headers="header1"><b>Onsolis</b>, soluble film (buccal)</td><td headers="header2">Fentanyl Citrate</td></tr>
<tr><td headers="header1"><b>Opana</b>, tablets (immediate release)</td><td headers="header2">Oxymorphone Hydrochloride</td></tr>
<tr><td headers="header1"><b>Opana ER</b>, tablets (extended release)</td><td headers="header2">Oxymorphone Hydrochloride</td></tr>
<tr><td headers="header1"><b>Oramorph SR</b>, tablets (sustained release)</td><td headers="header2">Morphine Sulfate</td></tr>
<tr><td headers="header1"><b>Oxecta</b>, tablets (immediate release)</td><td headers="header2">Oxycodone Hydrochloride</td></tr>
<tr><td headers="header1"><b>Oxycodone Hydrochloride</b>, capsules</td><td headers="header2">Oxycodone Hydrochloride</td></tr>
<tr><td headers="header1"><b>Oxycodone Hydrochlorid</b>e, oral solution</td><td headers="header2">Oxycodone Hydrochloride</td></tr>
<tr><td headers="header1"><b>Oxycontin</b>, tablets (extended release) *</td><td headers="header2">Oxycodone Hydrochloride</td></tr>
<tr><td headers="header1"><b>Percocet</b>, tablets <b>*</b></td><td headers="header2">Acetaminophen; Oxycodone Hydrochloride</td></tr>
<tr><td headers="header1"><b>Percodan</b>, tablets <b>*</b></td><td headers="header2">Aspirin; Oxycodone Hydrochloride</td></tr>
<tr><td><b>Xyrem</b>, oral solution</td><td>Sodium Oxybate</td></tr>
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<span style="font-family: 'trebuchet ms',helvetica,sans-serif;">By this time, fortunately, we have the benefit of a little experience with such guidelines and thoughtful review.(2)</span><span style="font-family: 'Trebuchet MS';"><b> </b><span style="font-family: 'trebuchet ms',helvetica,sans-serif;">The problem remains that American homes are filled with unused prescription drugs. "Each year we squirrel away 200 million pounds of pharmaceuticals we don't need anymore." Flushing or trashing drugs was the traditional means of disposal for decades, but in recent years take-back programs have been encouraged. The DEA has organized four nationwide take-back events since 2010. The most recent, in late April, collected more than 500,000 pounds of unwanted medications.</span></span> <span style="font-family: 'trebuchet ms',helvetica,sans-serif;">Flushing has fallen out of favor for all but a handful of drugs (see above) because of concerns about water contamination. Also we have data from Sweden that participation in take-back programs tends to stagnate at around 40%. New research, however, from the University of Michigan concludes that trashing drugs may be the most environmentally-friendly option. The researchers looked at the overall environmental impact of 3 disposal methods--flushing, trashing, and incineration. They analyzed how much of the drugs would enter the environment, emissions impacts from transportation, water treatment, and burning of waste materials. Their results show that flushing allows the highest levels of drugs to enter the environment by far, and creates more pollution than trashing. Drugs collected by take-back programs are incinerated, which means that none of the medicines themselves enter the environment, but these programs produce much greater emissions of green house gases and other pollutants than either flushing or trashing. This is mostly because consumers have to travel to a drop-off point and then the collected drugs are shipped somewhere else for incineration. The investigators suggest that home disposal is beneficial because we already have an infrastructure for collecting household trash. If our take-back programs are no more efficient than the Swedish programs, then our take-back program produces three times as much pollution while allowing about the same amount of drugs ultimately to reach the environment as home disposal in the trash. <b>COMMENT</b>: This suggestion makes a lot of sense. While the intention of take-back programs was to spare the environment, unless you take a more global perspective, you may be doing more harm than good. I, for one, appreciate being able to put my drugs back in the trash.</span></div>
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<span style="font-family: 'Trebuchet MS';"><b><u>REFERENCES</u></b>:</span></div>
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<span style="font-family: 'Trebuchet MS';"><span style="font-family: 'Trebuchet MS';"><span style="font-family: 'Trebuchet MS';">1. </span></span> Life Extension Magazine. May 2012. <a data-cke-saved-href="http://www.lef.org/magazine/mag2012/may2012_Nutrient-Cocktail-Delays-Aging-Extends-Life-Span_01.htm" href="https://app.icontact.com/icp/core/code/message/edit?token=cc6d094067e7a32ac25ffb10337340c6&iMessageId=31434380&sHubId=">Nutrient 'Cocktail' Delays Aging and Extends Life Span</a>.</span></div>
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<span style="font-family: 'Trebuchet MS';"> This article was brought to my attention by reader Phawda Moore.</span></div>
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<span style="font-family: 'Trebuchet MS';">2. NPR.org/blogs/health. <a data-cke-saved-href="http://www.npr.org/blogs/health/2012/05/17/152947334/trash-can-may-be-greenest-option-for-unused-drugs" href="https://app.icontact.com/icp/core/code/message/edit?token=cc6d094067e7a32ac25ffb10337340c6&iMessageId=31434380&sHubId=">Trash can may be greenest option for unused drugs</a>. accessed 9:53 am, May 18, 2012.</span></div>
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<br /></div>Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com2Vallejo, CA, USA38.1040864 -122.256636738.0041294 -122.4145652 38.2040434 -122.0987082tag:blogger.com,1999:blog-340176576888120508.post-63539970143140859842012-06-06T15:40:00.000-07:002012-06-06T15:40:15.846-07:00IS PATIENT SATISFACTION A GOOD THING FOR PATIENTS?<div style="text-align: center;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><b>A VIEW FROM THE OFFICE</b></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_NgUKHA15B3ARJC-YfwhbtXngqtVbSP62F3SBHCpam_5N_Lt8ME1XSSPLj8d45thDhvqzbNucltY5nChFLEsa3XTTQ2KCn6PWIsKrt12m8ILA3OLssLUAdhAOaasaNOz8Udm1XtjPB68/s1600/Portola+downtown.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_NgUKHA15B3ARJC-YfwhbtXngqtVbSP62F3SBHCpam_5N_Lt8ME1XSSPLj8d45thDhvqzbNucltY5nChFLEsa3XTTQ2KCn6PWIsKrt12m8ILA3OLssLUAdhAOaasaNOz8Udm1XtjPB68/s320/Portola+downtown.jpg" width="320" /></b></span></a></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><b>IS PATIENT SATISFACTION A GOOD THING FOR PATIENTS?</b></span></div>
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<span style="text-align: left;"><span style="font-family: 'Trebuchet MS';"><b> </b></span></span><span style="font-family: 'trebuchet ms', helvetica, sans-serif; text-align: left;">Almost all health care organizations are obsessed by patient satisfaction as an outcome measure. But think about it. <span style="color: #0c0c96;"><strong>Does a satisfied patient necessarily mean that the care was either good or effective? </strong></span>Patient satisfaction is well known to reduce law suits (if they like the doctor they are less likely to sue him/her), but it is also well known that patients who have liked their doctor over time are less likely to sue even if an egregious mistake was made. Patient satisfaction is really <strong><span style="color: #0c0c96;">just a subjective measure of a brief interaction</span></strong>. It is more sensitive to process problems like long waits, rude staff, doctor in a hurry, etc., which cumulatively can undermine the quality of care. But actually there is very little a patient can discern about whether his/her doctor was right, efficient, or cost-effective in his/her care. So is it enough just to measure the subjective quality of the experience? Do we have to give up on trying to understand anything about the 'quality' of the care? These questions are worth much further thought. This recent article provides that and comes to a surprising conclusion.(1)</span><br />
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<span style="font-family: 'trebuchet ms', helvetica, sans-serif;">These authors conducted a prospective cohort study of 51,946 adult respondents to the 2000-2007 national Medical Expenditure Panel Survey. Patient satisfaction was assessed using 5 items from the Consumer Assessment of Health Plans Survey. <span style="color: #0c0c96;"><strong>The positive correlate of patient satisfaction (in the highest quartile group) was a lower odds of any emergency department visit</strong></span> (OR 0.92; 95% CI, 0.84-1.00), which is a good thing. On the other hand, however, <span style="color: #b50e24;"><strong>this group had higher odds of an inpatient admission (OR 1.12), 8.8% higher total health expenditures, 9.1% higher prescription drug expenses, and higher mortality (OR 1.26, 95% CI, 1.05-1.53)</strong></span>.</span></div>
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<span style="font-family: 'trebuchet ms', helvetica, sans-serif;"> These findings are not completely out of line with limited prior research. Among a vulnerable older population, patient satisfaction had no association with the technical quality of geriatric care;(4) other evidence suggests that satisfaction has little or no correlation with Health Plan Employer Data and Information Set (HEDIS) quality metrics.(2,3) [Original References 3, 7, and 8] There are other data to suggest that physicians whose compensation is more strongly linked with patient satisfaction are more likely to deliver discretionary services (e.g. advanced imaging for acute low back pain).(5)</span></div>
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<span style="font-family: 'trebuchet ms', helvetica, sans-serif;"> </span><span style="font-family: 'trebuchet ms', helvetica, sans-serif;"> It is not certain what is going on here. Physicians may be just trying to keep patients happy by ordering tests, medications, and hospitalizations that are not really necessary. On the other hand, sicker patients may develop closer long-term, more satisfied, relationships with physicians who order appropriate tests and services. But the 26% greater mortality in this study strongly suggests that this is not an idle or trivial question to pursue. We don't want to kill our patients with kindness.</span></div>
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<span style="font-family: 'trebuchet ms', helvetica, sans-serif;">The authors comment: "In the ideal vision of patient-centered care, physicians deliver evidence-based care in accord with the preferences of informed patients, thereby improving satisfaction and health outcomes, while using health resources efficiently. However, patient-centered communication requires longer visits and may be challenging for many physicians to implement...Relaxing patient satisfaction incentives may encourage physician to prioritize the benefits of truthful therapeutic discourse, despite the risks of dissatisfying some patients."</span></div>
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<br />Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com1tag:blogger.com,1999:blog-340176576888120508.post-59145921819072557532012-05-03T13:28:00.005-07:002012-05-03T13:28:37.875-07:00<div class="separator" style="clear: both; text-align: center;">
<strong><span style="font-family: "Trebuchet MS", sans-serif;">SHOULD ORAL HEALTH BE A PART OF HEALTH CARE?</span></strong></div>
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<span style="font-family: Trebuchet MS;"><strong>DOES ORAL HEALTH HAVE A PLACE IN PRIMARY CARE?</strong></span></div>
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<span style="font-family: Trebuchet MS;"><strong>HOW IMPORTANT IS ORAL HEALTH IN PRIMARY CARE? </strong>This is a primordial gripe of mine--that in the US the people who set up health care have not noticed that oral health (i.e., teeth) are important to health. Existing statistics show that 33% of the entire US population is edentulous by age 60, all of which is easily preventable. This great neglect of oral health starts from the first day of medical school when students are taught how to do physical exams--"Open your mouth. Say "aaahhhh", and then they look at the uvula (an anatomic structure of no clinical significance) and the tonsils (which are irrelevant if the patient is not symptomatic with sore throat). Each and every time one of us does this part of the exam we are looking right past the teeth. Dental health turns out to be very easy to assess. If we hadn't been taught systematically to ignore it, it is something that we would do just because it was obvious. </span></div>
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<span style="font-family: Trebuchet MS;"> Whenever studies have been done to evaluate the most important components of a routine physical exam, the teeth and gums are always in the top 5 high-yield targets, both for pediatrics and adult medicine. (I mean, think of it; most of a comprehensive routine physical exam is pure wasted effort--but NOT the teeth!) So when was the last time, when you asked the patient to "Open up and say 'aaahhhh'," that you actually noted the status of the teeth and gums. Make an effort. It matters. Only if you catch these problems early can you manage them without dental referral. We, as primary care physicians, are the ones who get the biggest opportunity to see teeth and give instruction and advice that would be accepted.</span></div>
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<strong><span style="font-family: Trebuchet MS;">The Secrets of the Oral Health Exam</span></strong></div>
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<span style="font-family: Trebuchet MS;">1. <strong>Look for holes</strong>. Holes are not supposed to be there. Holes are easy to spot. If there is any question whether it is a hole or not, it is not a hole. Big holes are left by missing teeth, which are extremely obvious. Every physical exam should describe the approximate (%) of teeth that are either carious or missing.</span></div>
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<span style="font-family: Trebuchet MS;">2. <strong>Look at the gums (right up front--your nose is almost bumping into them when you look at the uvula)</strong>. Health gums should have nice, sharp, steep interdental pink tissue (papillae). The first sign of gum disease is that the tips of these become blunted and the height of the papilla becomes lower as the gums recede. This is a very early sign at a stage where it is still quite correctable with good hygiene. In the more advanced stage the entire gum recedes from the bottom of the exposed part of the teeth and you start to see the roots. Every physical exam of the head and neck should include a description of the height of the interdental papillae and the relative placing of the gum line across the normal neck of the teeth.</span></div>
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<span style="font-family: Trebuchet MS;"> People who have either of these findings should receive dental care. But, ay, there's the rub. Most of our patients will not have insurance for dental health. It is not regarded as part of general health coverage. We can get you a gastric bypass surgery but not a simple teeth cleaning. We sit back and wait for this time bomb to go off, and then the patient presents to the emergency room as the only place they can get any care for their acute dental pain. I am amazed at the number of patients I treated for recurrent tooth abscess with antibiotics. They take the antibiotics and a pain medication, but are unable to see a dentist for definitive treatment so they just come back in when it hurts again. And it goes on and on. What we need is a study that shows that good dental care saves general health costs down the road. I have never seen one. If you have, please let me know.</span></div>
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<span style="font-family: Trebuchet MS;"> Recently I got an email from a reader, Adam Jason, who has a special interest in this problem. He has prepared an <a data-cke-saved-href="http://frugaldad.com/dental/" href="javascript:void(0)/*250*/">infographic </a>available on the web. I share it with you here by permission. It is a worthy reminder of an important health and primary care issue.</span></div>
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Emergency Room Dentists: </h1>
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The High Costs of Life or Death Dental Care (Infographic)</h1>
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<span>Posted on </span><a data-cke-saved-href="http://frugaldad.com/dental/" href="http://frugaldad.com/dental/" rel="bookmark">April 10, 2012</a><span> <span>by </span><span><a data-cke-saved-href="http://frugaldad.com/author/jason/" href="http://frugaldad.com/author/jason/" rel="author">Jason (Frugal Dad)</a></span></span></div>
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It’s hard to believe but we seem to have forgotten about our teeth. We’ve been looking into the costs of America’s famously straight, white smiles. Instead of facts on cosmetic dentistry, we’ve come up with some troubling statistics on rapidly rising trend: emergency room dental visits. It turns out that dental care is suffering right along with general healthcare.<br />
Our latest graphic explains the costs and causes of this overall decline in preventative care. Dental care is really an investment against future costs, but we can’t blame the uninsured for avoiding costly cleanings and checkups. It’s a costly gamble to forego dental insurance. Routine checkups at the ER will get astronomical fast, not to mention the terrifying costs behind contracting a serious dental disease or injury.<br />
Going along with the infographic, it comes down to reform. Insurance-wise, it seems that dental costs need to be reduced in order for more employers to provide coverage. On an individual scale, it seems a more extensive dental hygiene regimen could really help Americans with or without insurance.<br />
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This entry was posted in <a data-cke-saved-href="http://frugaldad.com/category/infographic/" href="http://frugaldad.com/category/infographic/" rel="category tag">Infographic</a> by <a data-cke-saved-href="http://frugaldad.com/author/jason/" href="http://frugaldad.com/author/jason/">Jason (Frugal Dad)</a>. Bookmark the <a data-cke-saved-href="http://frugaldad.com/dental/" href="http://frugaldad.com/dental/" rel="bookmark">permalink</a>. <div>
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About Jason (Frugal Dad)</h2>
Jason founded FrugalDad.com in 2007, back when being frugal was still unpopular. <a data-cke-saved-href="https://plus.google.com/117911507509854857249?rel=author" href="https://plus.google.com/117911507509854857249?rel=author">My Google Profile+</a></div>
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</div>Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com2tag:blogger.com,1999:blog-340176576888120508.post-43839164997569014512012-05-02T17:04:00.003-07:002012-05-02T17:04:32.621-07:00HOW TO SAVE YOUR MIND WHEN ALL ABOUT YOU ARE LOSING THEIRS<div style="text-align: center;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><b>A VIEW FROM THE OFFICE</b></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><b>HOW TO SAVE YOUR MIND</b></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><b> </b>Your mind is a terrible thing to lose, and the fact is that you don't have to. I am often asked, "What can I do to prevent Alzheimer's disease?," and it turns out there is a nice, simple, effective answer, but it takes a lot of work. The answer is <span style="color: blue;"><b>exercise</b></span>. Chapter One of John <a href="http://brainrules.net/the-rules" target="_blank"><b>Medina's book</b></a>, <b><i>Brain Rules</i></b>, makes this point very nicely.</span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"> Research shows that overall the greatest predictor of successful aging was the presence or absence of a sedentary lifestyle. The primary benefit of exercise is to the heart and vascular system, but it also has a very specific benefit for brain function. "When couch potatoes are enrolled in an aerobic exercise program, <span style="color: blue;"><b>all kinds of mental abilities begin to come back online</b></span>. Positive results were observed after as little as four months of activity."</span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"> <br /> "A lifetime of exercise can result in a sometimes astonishing elevation in cognitive performance, compared with those who are sedentary. Exercisers outperform couch potatoes in tests that measure long-term memory, reasoning, attention, problem-solving, even so-called fluid-intelligence tasks (the ability to reason quickly and think abstractly, improvising off previously learned material in order to solve a new problem).</span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"> <b><span style="color: blue;">But how much activity does it take?</span></b> The encouraging answer is, "<span style="color: blue;"><b>Not much</b></span>." "If all you do is walk several times a week, your brain will benefit. Even couch potatoes who fidget show increased benefit over those who do not fidget." The effect is so significant that <span style="color: blue;"><b>your lifetime risk for general dementia is literally cut in <u>half</u> if you participate in leisure-time physical activity</b></span>. "Aerobic exercise seems to be the key. <span style="color: blue;"><b>With Alzheimer's, the effect is even greater: Such exercise lowers the odds of getting the disease by <u>more than 60 percent</u>.</b></span>" "You have to participate in some form of exercise just twice a week to get the benefit. Bump it up to a 20-minute walk each day, and <span style="color: blue;"><b>you can cut your risk of having a stroke...by 57%.</b></span>"</span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"> Exercise is also a powerful treatment for <span style="color: blue;"><b>depression </b></span>as it influences the neurotransmitters serotonin, dopamine, and norepinephrine. "For both depression and anxiety, exercise is beneficial immediately and over the long term. It is equally effective for men and women, and the longer the program is deployed, the greater the effect becomes. It is especially helpful for severe cases and for older people."</span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"> In fact, "the benefits of exercise seem nearly endless because its impact is system-wide, affecting most physiological systems. Exercise makes your muscles and bones stronger, for example, and improves your strength and balance. It helps regulate your appetite, changes your blood lipid profile, <span style="color: blue;"><b>reduces your risk for more than a dozen types of cancer</b></span>, improves the immune system, and buffers against the toxic effects of stress. By enriching your cardiovascular system, exercise decreases your risk for heart disease, stroke, and diabetes. When combined with the intellectual benefits exercise appears to offer, we have in our hands <span style="color: blue;"><b>as close to a magic bullet for improving human health as exists in modern medicine</b></span>."</span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"> How did exercise become so important in the history of the survival of our species. The answer is pretty simple--once upon a time, it was necessary. Our prehistoric ancestors in the homo species (erectus and sapiens) walked about 10 to 20 kilometers a day for men and about half that for women in the pursuit of food. That's 12 miles a day. In addition the species was steadily expanding its range--by about 25 miles per year. Survival required constant motion, quick reflexes, and quick thinking. What's unfortunate is that <span style="color: blue;"><b>survival (in good health) still requires that even when it is not obvious</b></span>.</span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"> If you've drifted away from this healthy habit over the course of your life, don't despair. The <b>Atherosclerosis Risk Factors in Communities Study (ARIC)</b> has shown that even long-term couch potatoes with no healthy habits who convert to not smoking, exercising 20 minutes a day, eating 5 servings of fruits and vegetables a day, and getting their BMI to less than 30, <span style="color: blue;"><b>enjoy a 40% reduction in mortality over a period as short as 4 years.</b></span> It's really amazing that it only takes 4 years of good habits to make up for a lifetime of bad habits. You can do it.</span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"> So, why not take advantage of this simple secret. It's easy to do. Dr. Medina offers two simple suggestions: (1) <b><span style="color: blue;">Wear your gym clothes all day</span></b>. Eliminate the barrier to exercise that changing clothes imposes. Employers should encourage this. (2) Adapt yourself during your PC time <span style="color: blue;"><b>managing email or surfing the web by doing it while on a treadmill</b></span>. Dr. Medina says it took him only 15 minutes to become fully proficient on the laptop keyboard while walking at a 1.8 mile per hour pace. My additional suggestion is to find a way to capitalize on our preference, nay, need for, <span style="color: blue;"><b>regular rituals</b></span>. Create either four 5-minute ritual walks for your every day routine--walking to the store or post office, exploring a neighborhood park, walking from the parking lot to work or up several flights of stairs, etc., or create two 10-minute rituals. Whatever works for you--it just needs to add up to 20 minutes a day every (or almost every) day. And, either <span style="color: blue;"><b>before your walk or right after, consume a fruit or vegetable (a smoothie or a glass of V8 juice)</b></span>, and then <span style="color: blue;"><b>relax</b></span>. Hey, you've got the whole lifestyle challenge beat according to the "<span style="color: #38761d;"><b>Formula for Health</b></span>", assuming you're not smoking and your weight (read "BMI") is heading down to 30 or below.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgt-B5ZHBU6K32-ypo-5lnC-ui6hdc3RZd4nCd8DGMm2ecgSZ4oB1oGH52kxi46HleILvuHU3jH-HKsoWfwwRYxXAMe6G6vGPXSs3Sl7i7vUJUNSrInns-SdqSSkvRG93UJ1DKBw-j34z4/s1600/EPHC+Lifestyle+poster+2-sided%255B1%255D_Page_2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgt-B5ZHBU6K32-ypo-5lnC-ui6hdc3RZd4nCd8DGMm2ecgSZ4oB1oGH52kxi46HleILvuHU3jH-HKsoWfwwRYxXAMe6G6vGPXSs3Sl7i7vUJUNSrInns-SdqSSkvRG93UJ1DKBw-j34z4/s640/EPHC+Lifestyle+poster+2-sided%255B1%255D_Page_2.jpg" width="484" /></a></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"> You could even organize a neighborhood outing for 10-15 minutes every day after work. Invite the local kids and their parents to join you for a walk or ride. Making this kind of activity communal is the single best contribution you can make for your community. It will be immensely rewarding.</span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"> And remember, you don't need to get Alzheimer's disease. It is essentially completely preventable.</span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;">REFERENCE:</span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;">Medina J. Brain Rules: 12 Principles for Surviving and Thriving at Work, Home, and School. Pear Press. 2008.</span></div>
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<tr class="bucketBorderTop" id="tmm_B0041KLCH0"><td class="tmm_buttonTD" style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; height: 22px; line-height: 1.2em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: middle; width: 22px;"><a href="http://www.amazon.com/Brain-Rules-Principles-Surviving-Thriving/dp/0979777747/ref=sr_1_1?ie=UTF8&qid=1336000120&sr=8-1#" id="kindle_meta_binding_showMoreButton" style="color: #004b91; visibility: hidden;"><span class="s_expandTMM swSprite" style="background-attachment: scroll; background-clip: initial; background-color: transparent; background-image: url(http://g-ecx.images-amazon.com/images/G/01/twister/images/twister_books_sprite._V166092224_.gif); background-origin: initial; background-position: 5px 5px; background-repeat: no-repeat no-repeat; display: inline-block; height: 22px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; overflow-x: hidden; overflow-y: hidden; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; position: relative; vertical-align: middle; width: 22px;"><span style="left: -9999px; position: absolute;"></span></span></a></td><td class="tmm_bookTitle noLinkDecoration " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; vertical-align: top;"><a href="http://www.amazon.com/Brain-Rules-Principles-Surviving-ebook/dp/B0041KLCH0/ref=tmm_kin_title_0?ie=UTF8&m=AG56TWVU5XWC2&qid=1336000120&sr=8-1" style="border-bottom-color: initial; border-bottom-style: none; border-bottom-width: initial; color: #004b91; text-decoration: none;">Kindle Edition</a></td><td class=" price " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; color: #990000; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; text-align: right; vertical-align: top; white-space: nowrap;">$7.16</td><td class=" noLinkDecoration " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; vertical-align: top;"> </td><td class="tmm_olpLinks " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; text-align: right; vertical-align: top; white-space: nowrap;">--</td><td class="tmm_olpLinks " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; text-align: right; vertical-align: top; white-space: nowrap;">--</td></tr>
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<tr class="bucketBorderTop" id="tmm_0979777704"><td class="tmm_buttonTD" style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; height: 22px; line-height: 1.2em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: middle; width: 22px;"><a href="http://www.amazon.com/Brain-Rules-Principles-Surviving-Thriving/dp/0979777747/ref=sr_1_1?ie=UTF8&qid=1336000120&sr=8-1#" id="hardcover_meta_binding_showMoreButton" style="color: #004b91;"><span class="s_expandTMM swSprite" style="background-attachment: scroll; background-clip: initial; background-color: transparent; background-image: url(http://g-ecx.images-amazon.com/images/G/01/twister/images/twister_books_sprite._V166092224_.gif); background-origin: initial; background-position: 5px 5px; background-repeat: no-repeat no-repeat; display: inline-block; height: 22px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; overflow-x: hidden; overflow-y: hidden; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; position: relative; vertical-align: middle; width: 22px;"><span style="left: -9999px; position: absolute;">Expand</span></span></a></td><td class="tmm_bookTitle noLinkDecoration " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; vertical-align: top;"><a href="http://www.amazon.com/Brain-Rules-Principles-Surviving-Thriving/dp/0979777704/ref=tmm_hrd_title_0?ie=UTF8&qid=1336000120&sr=8-1" style="border-bottom-color: initial; border-bottom-style: none; border-bottom-width: initial; color: #004b91; text-decoration: none;">Hardcover</a></td><td class=" price " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; color: #990000; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; text-align: right; vertical-align: top; white-space: nowrap;">$18.54</td><td class=" noLinkDecoration " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; vertical-align: top;"><span class="s_primeBadgeTMM swSprite" style="background-attachment: scroll; background-clip: initial; background-color: transparent; background-image: url(http://g-ecx.images-amazon.com/images/G/01/twister/images/twister_books_sprite._V166092224_.gif); background-origin: initial; background-position: -40px 0px; background-repeat: no-repeat no-repeat; display: inline-block; height: 12px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; overflow-x: hidden; overflow-y: hidden; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; position: relative; vertical-align: middle; width: 41px;"></span></td><td class="tmm_olpLinks " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; text-align: right; vertical-align: top; white-space: nowrap;"><a href="http://www.amazon.com/gp/offer-listing/0979777704/ref=tmm_hrd_new_olp_0?ie=UTF8&qid=1336000120&sr=8-1&condition=new" style="color: #004b91; text-decoration: none;">$14.99</a></td><td class="tmm_olpLinks " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; text-align: right; vertical-align: top; white-space: nowrap;"><a href="http://www.amazon.com/gp/offer-listing/0979777704/ref=tmm_hrd_used_olp_0?ie=UTF8&qid=1336000120&sr=8-1&condition=used" style="color: #004b91; text-decoration: none;">$6.64</a></td></tr>
</tbody><tbody id="hardcover_meta_binding_body"></tbody><tbody></tbody><tbody id="paperback_meta_binding_winner">
<tr class="activeRow bucketBorderTop" id="tmm_0979777747"><td class="tmm_buttonTD" style="background-color: #fcfcc2; border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; height: 22px; line-height: 1.2em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: middle; width: 22px;"><a href="http://www.amazon.com/Brain-Rules-Principles-Surviving-Thriving/dp/0979777747/ref=sr_1_1?ie=UTF8&qid=1336000120&sr=8-1#" id="paperback_meta_binding_showMoreButton" style="color: #004b91;"><span class="s_expandTMM swSprite" style="background-attachment: scroll; background-clip: initial; background-color: transparent; background-image: url(http://g-ecx.images-amazon.com/images/G/01/twister/images/twister_books_sprite._V166092224_.gif); background-origin: initial; background-position: 5px 5px; background-repeat: no-repeat no-repeat; display: inline-block; height: 22px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; overflow-x: hidden; overflow-y: hidden; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; position: relative; vertical-align: middle; width: 22px;"><span style="left: -9999px; position: absolute;">Expand</span></span></a></td><td class="tmm_bookTitle noLinkDecoration " style="background-color: #fcfcc2; border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; vertical-align: top;">Paperback</td><td class=" price " style="background-color: #fcfcc2; border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; color: #990000; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; text-align: right; vertical-align: top; white-space: nowrap;">$10.20</td><td class=" noLinkDecoration " style="background-color: #fcfcc2; border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; vertical-align: top;"><span class="s_primeBadgeTMM swSprite" style="background-attachment: scroll; background-clip: initial; background-color: transparent; background-image: url(http://g-ecx.images-amazon.com/images/G/01/twister/images/twister_books_sprite._V166092224_.gif); background-origin: initial; background-position: -40px 0px; background-repeat: no-repeat no-repeat; display: inline-block; height: 12px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; overflow-x: hidden; overflow-y: hidden; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; position: relative; vertical-align: middle; width: 41px;"></span></td><td class="tmm_olpLinks " style="background-color: #fcfcc2; border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; text-align: right; vertical-align: top; white-space: nowrap;"><a href="http://www.amazon.com/gp/offer-listing/0979777747/ref=tmm_pap_new_olp_sr?ie=UTF8&qid=1336000120&sr=8-1&condition=new" style="color: #004b91; text-decoration: none;">$7.99</a></td><td class="tmm_olpLinks " style="background-color: #fcfcc2; border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; text-align: right; vertical-align: top; white-space: nowrap;"><a href="http://www.amazon.com/gp/offer-listing/0979777747/ref=tmm_pap_used_olp_sr?ie=UTF8&qid=1336000120&sr=8-1&condition=used" style="color: #004b91; text-decoration: none;">$6.10</a></td></tr>
</tbody><tbody id="paperback_meta_binding_body"></tbody><tbody></tbody><tbody id="audiobooks_meta_binding_winner">
<tr class="bucketBorderTop" id="tmm_0979777712"><td class="tmm_buttonTD" style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; height: 22px; line-height: 1.2em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: middle; width: 22px;"><a href="http://www.amazon.com/Brain-Rules-Principles-Surviving-Thriving/dp/0979777747/ref=sr_1_1?ie=UTF8&qid=1336000120&sr=8-1#" id="audiobooks_meta_binding_showMoreButton" style="color: #004b91;"><span class="s_expandTMM swSprite" style="background-attachment: scroll; background-clip: initial; background-color: transparent; background-image: url(http://g-ecx.images-amazon.com/images/G/01/twister/images/twister_books_sprite._V166092224_.gif); background-origin: initial; background-position: 5px 5px; background-repeat: no-repeat no-repeat; display: inline-block; height: 22px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; overflow-x: hidden; overflow-y: hidden; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; position: relative; vertical-align: middle; width: 22px;"><span style="left: -9999px; position: absolute;">Expand</span></span></a></td><td class="tmm_bookTitle noLinkDecoration " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; vertical-align: top;"><a href="http://www.amazon.com/Brain-Rules-Principles-Surviving-Thriving/dp/0979777712/ref=tmm_abk_title_0?ie=UTF8&qid=1336000120&sr=8-1" style="border-bottom-color: initial; border-bottom-style: none; border-bottom-width: initial; color: #004b91; text-decoration: none;">Audio, CD, Abridged, Audiobook, CD</a></td><td class=" price " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; color: #990000; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; text-align: right; vertical-align: top; white-space: nowrap;">$29.88</td><td class=" noLinkDecoration " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; vertical-align: top;"><span class="s_primeBadgeTMM swSprite" style="background-attachment: scroll; background-clip: initial; background-color: transparent; background-image: url(http://g-ecx.images-amazon.com/images/G/01/twister/images/twister_books_sprite._V166092224_.gif); background-origin: initial; background-position: -40px 0px; background-repeat: no-repeat no-repeat; display: inline-block; height: 12px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; overflow-x: hidden; overflow-y: hidden; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; position: relative; vertical-align: middle; width: 41px;"></span></td><td class="tmm_olpLinks " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; text-align: right; vertical-align: top; white-space: nowrap;"><a href="http://www.amazon.com/gp/offer-listing/0979777712/ref=tmm_abk_new_olp_0?ie=UTF8&qid=1336000120&sr=8-1&condition=new" style="color: #004b91; text-decoration: none;">$18.71</a></td><td class="tmm_olpLinks " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; text-align: right; vertical-align: top; white-space: nowrap;"><a href="http://www.amazon.com/gp/offer-listing/0979777712/ref=tmm_abk_used_olp_0?ie=UTF8&qid=1336000120&sr=8-1&condition=used" style="color: #004b91; text-decoration: none;">$18.71</a></td></tr>
</tbody><tbody id="audiobooks_meta_binding_body"></tbody><tbody></tbody><tbody id="other_meta_binding_winner">
<tr class="bucketBorderTop" id="tmm_B004IZBVR4"><td class="tmm_buttonTD" style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; height: 22px; line-height: 1.2em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: middle; width: 22px;"><a href="http://www.amazon.com/Brain-Rules-Principles-Surviving-Thriving/dp/0979777747/ref=sr_1_1?ie=UTF8&qid=1336000120&sr=8-1#" id="other_meta_binding_showMoreButton" style="color: #004b91;"><span class="s_expandTMM swSprite" style="background-attachment: scroll; background-clip: initial; background-color: transparent; background-image: url(http://g-ecx.images-amazon.com/images/G/01/twister/images/twister_books_sprite._V166092224_.gif); background-origin: initial; background-position: 5px 5px; background-repeat: no-repeat no-repeat; display: inline-block; height: 22px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; overflow-x: hidden; overflow-y: hidden; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; position: relative; vertical-align: middle; width: 22px;"><span style="left: -9999px; position: absolute;">Expand</span></span></a></td><td class="tmm_bookTitle noLinkDecoration " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; vertical-align: top;"><a href="http://www.amazon.com/Brain-Rules-Principles-Surviving-Paperback/dp/B004IZBVR4/ref=tmm_other_meta_binding_title_0?ie=UTF8&qid=1336000120&sr=8-1" style="border-bottom-color: initial; border-bottom-style: none; border-bottom-width: initial; color: #004b91; text-decoration: none;">Unknown Binding</a></td><td class=" price " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; color: #990000; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; text-align: right; vertical-align: top; white-space: nowrap;">--</td><td class=" noLinkDecoration " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; vertical-align: top;"> </td><td class="tmm_olpLinks " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; text-align: right; vertical-align: top; white-space: nowrap;"><a href="http://www.amazon.com/gp/offer-listing/B004IZBVR4/ref=tmm_other_meta_binding_new_olp_0?ie=UTF8&qid=1336000120&sr=8-1&condition=new" style="color: #004b91; text-decoration: none;">$8.41</a></td><td class="tmm_olpLinks " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; text-align: right; vertical-align: top; white-space: nowrap;"><a href="http://www.amazon.com/gp/offer-listing/B004IZBVR4/ref=tmm_other_meta_binding_used_olp_0?ie=UTF8&qid=1336000120&sr=8-1&condition=used" style="color: #004b91; text-decoration: none;">$13.80</a></td></tr>
</tbody><tbody id="other_meta_binding_body"></tbody><tbody></tbody><tbody id="audiobooks_digital_meta_binding_winner">
<tr class="bucketBorderTop" id="tmm_B0017KP8AE"><td class="tmm_buttonTD" style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; height: 22px; line-height: 1.2em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: middle; width: 22px;"><a href="http://www.amazon.com/Brain-Rules-Principles-Surviving-Thriving/dp/0979777747/ref=sr_1_1?ie=UTF8&qid=1336000120&sr=8-1#" id="audiobooks_digital_meta_binding_showMoreButton" style="color: #004b91; visibility: hidden;"><span class="s_expandTMM swSprite" style="background-attachment: scroll; background-clip: initial; background-color: transparent; background-image: url(http://g-ecx.images-amazon.com/images/G/01/twister/images/twister_books_sprite._V166092224_.gif); background-origin: initial; background-position: 5px 5px; background-repeat: no-repeat no-repeat; display: inline-block; height: 22px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; overflow-x: hidden; overflow-y: hidden; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; position: relative; vertical-align: middle; width: 22px;"><span style="left: -9999px; position: absolute;"></span></span></a></td><td class="tmm_bookTitle noLinkDecoration " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; vertical-align: top;"><a href="http://www.amazon.com/Brain-Rules-Principles-Surviving-Thriving/dp/B0017KP8AE/ref=tmm_aud_title_0?ie=UTF8&qid=1336000120&sr=8-1" style="border-bottom-color: initial; border-bottom-style: none; border-bottom-width: initial; color: #004b91; text-decoration: none;">Audible Audio Edition, Unabridged</a></td><td class=" price " style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; color: #990000; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; text-align: right; vertical-align: top; white-space: nowrap;"><span class="price">$9.95</span></td><td class=" noLinkDecoration " colspan="3" style="border-top-color: rgb(240, 240, 240); border-top-style: solid; border-top-width: 1px; font-size: 11px !important; line-height: 1.2em; padding-bottom: 4px; padding-left: 4px; padding-right: 4px; padding-top: 4px; vertical-align: top;"><span class="tmm_audibleMessage" style="color: #666666;">or <span class="price" style="color: #990000; text-align: right; white-space: nowrap;">Free</span> with Audible 30-day free trial</span></td></tr>
</tbody></table>
</div>
</div>
</td></tr>
</tbody></table>
<br /><b><span style="font-family: 'Trebuchet MS', sans-serif;">NOTE: I will be in Portola this weekend for the Saturday morning clinic. I hope to see you there!</span></b><div class="separator" style="clear: both; text-align: center;">
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</div>Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com3tag:blogger.com,1999:blog-340176576888120508.post-68260551148853954252012-04-24T11:07:00.002-07:002012-04-24T11:07:37.526-07:00IS YOUR 'CHECK ENGINE' LIGHT ON?<div style="text-align: center;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><b>A VIEW FROM THE OFFICE</b></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><b>IS YOUR 'CHECK ENGINE' LIGHT ON?</b></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><b><br /></b></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><b> </b>Have you ever been annoyed by <span style="color: blue;"><b>your car's 'check engine' light</b></span>? I mean, have you responded to this light and taken the car in to be checked, only to find there was nothing really wrong and nothing to be done. [This analogy is provided by Dr. H. Gilbert Welch in his book "<span style="color: purple;"><b><i>Overdiagnosis: Making People Sick in the Pursuit of Health</i></b></span>".] The problem now is that your car is so computerized that it even has sensors to detect the function of other sensors. At a certain degree of complexity something has to be at least slightly askew a large fraction of the time. The point that Dr. Welch makes is that getting frequent recommended medical check-ups produces essentially the same result. Your doctor will likely tell you on most of these occasions that <span style="color: blue;"><b>"you're 'check engine' light is on" </b></span>and there's something you have to do to turn it off (despite the often overwhelming odds that everything is just fine). Examples of such situations include the mammogram or chest x-ray with a "<span style="color: red;"><b>suspicious spot</b></span>," the Pap smear with minor abnormalities like "<span style="color: red;"><b>ASCUS</b></span>," the <span style="color: red;"><b>stool blood test</b></span> that is positive (due to hemorrhoids, which are much more common than colon cancer), the <span style="color: red;"><b>blood pressure that is elevated 10 mm Hg</b></span> more than usual, the <span style="color: red;"><b>freckle </b></span>that looks just slightly darker than all the other ones, etc. The question for you the patient should be, How often are you metaphorically willing to have your engine checked? It can get to be quite a nuisance. Even more than that, as Dr. Welch points out, <span style="color: blue;"><b>it can at times be frankly hazardous to your health</b></span>.</span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"> Consider this table that he provides for us [his table 2.1]. In it he shows the effects when, hopefully, well-meaning "experts" decide to <b><span style="color: blue;">change the criteria for diagnosis of common conditions</span></b>. Their imputed motivation for doing this is to catch more people with this condition [i.e., their 'check engine' light is on], so that we might prevent more bad disease outcomes like blindness from diabetes, stroke from hypertension, a heart attack for high cholesterol, and a compression fracture from osteoporosis. <span style="color: blue;"><b>The problem is that at the lower range of these physiological variables there are actually a few bad outcomes, but only a very few</b></span>. As you can see in the table, as you lower the threshold for diagnosing diabetes, hypertension, high cholesterol, and osteoporosis, <span style="color: red;"><b>you are instantly creating literally millions of patients with a "new" disease condition</b></span>. They are now "sick" and are expected to get "treatment." Only a small percent of such newly diagnosed patients (typically 1-8%) will benefit from this treatment; essentially, a minimum of 92% of the new diagnoses are being subjected to medical scrutiny, testing, and treatment with absolutely no benefit to show for it.</span></div>
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<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<b><span style="font-family: Arial, Helvetica, sans-serif;">CONDITION<o:p></o:p></span></b></div>
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<td colspan="2" style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 153.0pt;" valign="top" width="204">
<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<b><span style="font-family: Arial, Helvetica, sans-serif;">PREVALENCE<o:p></o:p></span></b></div>
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<td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 67.5pt;" valign="top" width="90">
<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<b><span style="font-family: Arial, Helvetica, sans-serif;">NEW
CASES<o:p></o:p></span></b></div>
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<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<b><span style="font-family: Arial, Helvetica, sans-serif;">%
INCREASE<o:p></o:p></span></b></div>
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<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 185.4pt;" valign="top" width="247">
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<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<b><span style="font-family: Arial, Helvetica, sans-serif;">Old
criterion<o:p></o:p></span></b></div>
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<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 76.5pt;" valign="top" width="102">
<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<b><span style="font-family: Arial, Helvetica, sans-serif;">New
Criterion<o:p></o:p></span></b></div>
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<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 67.5pt;" valign="top" width="90">
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<br /></div>
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<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 72.9pt;" valign="top" width="97">
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<br /></div>
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<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 185.4pt;" valign="top" width="247">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;"><b>Diabetes</b>: the criterion
for diagnosis was changed from a sugar level of 140 down to 126 mg%.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 76.5pt;" valign="top" width="102">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;"> 11,697,000</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 76.5pt;" valign="top" width="102">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;">13,378,000</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 67.5pt;" valign="top" width="90">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;">1,681,000</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 72.9pt;" valign="top" width="97">
<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">14%</span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 185.4pt;" valign="top" width="247">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;"><b>Hypertension</b>: the
criterion for diagnosis was changed from 160/100 to 140/90 mm Hg.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 76.5pt;" valign="top" width="102">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;">38,690,000</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 76.5pt;" valign="top" width="102">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;">52,180,000</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 67.5pt;" valign="top" width="90">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;">13,490,000</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 72.9pt;" valign="top" width="97">
<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">35%</span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 185.4pt;" valign="top" width="247">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;"><b>High cholesterol</b>: the
criterion for diagnosis was changed
from a total cholesterol of 240 mg to 200 mg/dL.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 76.5pt;" valign="top" width="102">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;">49,480,000</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 76.5pt;" valign="top" width="102">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;">92,127,000</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 67.5pt;" valign="top" width="90">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;">42,647,000</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 72.9pt;" valign="top" width="97">
<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">86%</span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 185.4pt;" valign="top" width="247">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;"><b>Osteoporosis</b>: The
criterion for diagnosis was changed from a “T score” of 2.5 to 2.0</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 76.5pt;" valign="top" width="102">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;">8,010,000</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 76.5pt;" valign="top" width="102">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;">14,791,000</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 67.5pt;" valign="top" width="90">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;">6,781,000</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 72.9pt;" valign="top" width="97">
<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">85%</span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: 'Trebuchet MS', sans-serif;">The other problem is that <b><span style="color: red;">the motivation for these new diagnostic criteria among the "experts" is not always beneficent</span></b>. Often it is frankly commercial. "The head of the diabetes cutoff panel was a paid consultant to Aventis Pharmaceuticals, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Novartis, Merck, and Pfizer--all of which make diabetes drugs. Nine of the eleven authors of recent high blood pressure guidelines had some kind of financial ties--as paid consultants, paid speakers, or grant recipients--to drug companies that made high blood pressure drugs. Similarly, eight of the nine experts who lowered the cholesterol cutoff were paid consultants to drug companies making cholesterol drugs. and the first cutoff for osteoporosis was established by a World health Organization panel in partnership with the International Osteoporosis Foundation--an organization whose corporate advisory board consisted of thirty-one drug and medical equipment companies."</span></div>
<div class="MsoNormal">
<span style="font-family: 'Trebuchet MS', sans-serif;"> Dr. Welch summarizes the outcomes for persons affected by these new guidelines in this table: </span></div>
<div class="MsoNormal">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal">
</div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
<tr>
<td colspan="4" style="border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 6.65in;" valign="top" width="638">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<b><i>“If 100 patients are diagnosed on the basis of elevated but near
normal levels of a variable and treated for a lifetime, there will be…”<o:p></o:p></i></b></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" valign="top" width="160">
<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<b><span style="font-family: Arial, Helvetica, sans-serif;">CONDITION<o:p></o:p></span></b></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" valign="top" width="160">
<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<b><span style="font-family: Arial, Helvetica, sans-serif;"><span style="color: #38761d;">WINNERS</span><o:p></o:p></span></b></div>
<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">(avoided a heart attack)</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" valign="top" width="160">
<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;"><b>TREATED
FOR NAUGHT</b> (had a bad outcome despite treatment)</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" valign="top" width="160">
<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<b><span style="font-family: Arial, Helvetica, sans-serif;"><span style="color: #cc0000;">LOSERS</span><o:p></o:p></span></b></div>
<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">(not helped because they were never
going to have a heart attack anyway)</span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" valign="top" width="160">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: Arial, Helvetica, sans-serif;">Mildly elevated <b>cholesterol</b></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" valign="top" width="160">
<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">8</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" valign="top" width="160">
<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">14</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" valign="top" width="160">
<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">78</span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" valign="top" width="160">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: Arial, Helvetica, sans-serif;">Mildly low T score for <b>osteoporosis</b></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" valign="top" width="160">
<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">5</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" valign="top" width="160">
<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">44</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" valign="top" width="160">
<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">51</span></div>
</td>
</tr>
</tbody></table>
<br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: 'Trebuchet MS', sans-serif;">This problem also exists with all our fancy new imaging technologies like CT scans and MRIs, as well as for old technologies like plain x-rays and ultrasounds. Here are some typical examples:</span></div>
<div class="MsoNormal">
</div>
<ul>
<li><span style="font-family: 'Trebuchet MS', sans-serif;">"<b>Gallstones</b>: In people without any symptoms of gallbladder disease (pain, nausea, or problems with fatty foods, for example), about 10% have gallstones when scanned by ultrasound.</span></li>
<li><span style="font-family: 'Trebuchet MS', sans-serif;">"<b>Damaged knee cartilage</b>: In people without knee pain or a history of knee injury, about 40% have meniscal damage in their knees when scanned by MRI.</span></li>
<li><span style="font-family: 'Trebuchet MS', sans-serif;">"<b>Bulging discs in the back</b>: In people without any back pain, over 50% have bulging lumbar discs when scanned by MRI."</span></li>
</ul>
<div>
<span style="font-family: 'Trebuchet MS', sans-serif;"> And, of course, as I have said in prior blogs, this problem applies to cancer screening. I have already covered prostate cancer, cervical cancer, colon cancer, and breast cancer. Let's take a look at 3 other relatively common cancers--thyroid cancer, melanoma, and lung cancer. </span></div>
<div>
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div>
<span style="font-family: 'Trebuchet MS', sans-serif;"><b><u>Thyroid cancer</u></b>: Thyroid cancer is responsible for about 1,600 deaths each year in the US. The number of cases of thyroid cancer diagnosed each year in the US is much greater --37,000 cases. This discrepancy is explained by two basic factors: (1) treatment for the most common thyroid cancers is pretty good; and (2) there is a large portion of thyroid cancers that exist in asymptomatic patients and which is never going to cause any symptoms. <span style="color: blue;"><b>In one autopsy study of 101 older patients who had died of other causes in a hospital, pathologists found clusters of thyroid cancer cells in a full 33% of patients</b></span>. The researchers in this study concluded that "<b><span style="color: blue;">the smallest forms of thyroid cancer were so common that they should be regarded as normal findings</span></b>." The moral of this story is that <span style="color: red;"><b>you don't really want your doctor examining your neck (thyroid gland) for lumps </b></span>because nodules are extremely common (now that we use ultrasound routinely; prevalence is 30-65%), yet death from thyroid cancer is very rare. The United States Preventive Services Task Force recommended against any form of routine thyroid cancer screening in 1996.</span></div>
<div>
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div>
<span style="font-family: 'Trebuchet MS', sans-serif;"><b><u>Melanoma</u></b>: There are about 8,400 deaths in the US each year from malignant melanoma. The incidence of melanoma, however, is much higher--around 116,000 cases per year. In recent years there have been many efforts directed at increasing early diagnosis of melanoma and these have resulted in a doubling of the number of cases diagnosed between 1975 and 2005. It would seem like that should be a good thing. But when you look at the annual death rate from melanoma in the same period there has been absolutely no change. This means that all of these extra diagnoses have not reduced the death rate. We have just labelled more people with a diagnosis of melanoma that was going to have no effect on the overall death rate. What we are finding with our increased tendency to biopsy pigmented lesions is that there are many people who have microscopic clusters of abnormal melanin-producing cells who were never going to have any clinical disease from it. Increased screening does not appear to be helping at all. </span></div>
<div>
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div>
<span style="font-family: 'Trebuchet MS', sans-serif;"><b><u>Lung cancer</u></b>: "From a public health perspective, lung cancer is the cancer that warrants the most attention. It's responsible for 162,000 deaths annually in the US. That's more than breast cancer, prostate cancer, melanoma, thyroid cancer, and colon cancer combined. About 215,000 Americans get the diagnosis annually. That means most people diagnosed with lung cancer die from it." Since we know that people who smoke or used to smoke are the ones who have the highest risk for lung cancer, you would think it might make sense to screen this group of patients for lung cancer. If so, you would be wrong.</span></div>
<div>
<span style="font-family: 'Trebuchet MS', sans-serif;"> Three randomized trials completed in the 1990s showed the screening chest x-rays did not lead to a reduction in lung cancer deaths. "In fact, in two of the studies, <span style="color: red;"><b>screening appeared to cause more deaths.</b></span>" Virtually all cases identified by screening underwent surgery, and the surgery has a significant mortality rate. But this is not the only problem. The other problem is that, <span style="color: blue;"><b>after 20 years of follow-up, it appears that approximately 50% of all cancers detected by screening were lung cancers that were small and were never going to cause a problem</b></span>, yet almost all of these "overdiagnosed" patients underwent surgery.</span></div>
<div>
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div>
<span style="font-family: 'Trebuchet MS', sans-serif;"> Finally, there is the problem of "<b>incidentalomas</b>". This is a new term in medical jargon that refers to abnormal findings on an imaging procedure that was carried out for a purpose unrelated to cancer screening. For example, if a chest CT scan is done for a pulmonary problem, it may also unexpectedly find a "<span style="color: red;"><b>spot</b></span>" in the liver or kidney. If an ultrasound is done on a carotid artery to assess circulation, it may also see a <span style="color: red;"><b>cyst </b></span>or <span style="color: red;"><b>nodule </b></span>in the thyroid gland. </span></div>
<div>
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div>
<div class="MsoNormal">
.</div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
<tr>
<td style="border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<b><span style="font-family: Arial, Helvetica, sans-serif;">Organ<o:p></o:p></span></b></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<b><span style="font-family: Arial, Helvetica, sans-serif;">% of people with an
incidentaloma on CT scan<o:p></o:p></span></b></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<b><span style="font-family: Arial, Helvetica, sans-serif;">10-year risk of cancer death<o:p></o:p></span></b></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<b><span style="font-family: Arial, Helvetica, sans-serif;">Maximal chance that the
incidentaloma is a lethal cancer <o:p></o:p></span></b></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.8pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<b><span style="font-family: Arial, Helvetica, sans-serif;">Chance that the incidentaloma
is NOT a lethal cancer<o:p></o:p></span></b></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;"><b>Lung </b>(smokers)<b><o:p></o:p></b></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">50%</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">1.8%</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">3.6%</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.8pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">96.4%</span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;"><b>Lung </b></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;">(never smokers)<b><o:p></o:p></b></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">15%</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">0.1%</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">0.7%</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.8pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">99.3%</span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<b><span style="font-family: Arial, Helvetica, sans-serif;">Kidney<o:p></o:p></span></b></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">23%</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">0.05%</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">0.2%</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.8pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">99.8%</span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<b><span style="font-family: Arial, Helvetica, sans-serif;">Liver<o:p></o:p></span></b></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">15%</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">0.08%</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">0.5%</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.8pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">99.5%</span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Arial, Helvetica, sans-serif;"><b>Thyroid </b>(ultrasound)<b><o:p></o:p></b></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">67%</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">0.005%</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.75pt;" valign="top" width="128">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Arial, Helvetica, sans-serif;">< 0.01%</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 95.8pt;" valign="top" width="128">
<div class="MsoListParagraph" style="margin-bottom: 0.0001pt; margin-left: 37.5pt; margin-right: 0in; margin-top: 0in; text-align: center; text-indent: -0.25in;">
<!--[if !supportLists]--><span style="font-family: Arial, Helvetica, sans-serif;">Ø<span style="font-size: 7pt;">
</span><!--[endif]-->99.99%</span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal">
.</div>
</div>
<br />
<br />
<div class="MsoNormal">
<span style="font-family: 'Trebuchet MS', sans-serif;">When you reflect on the data in this table, it should be clear to the average person that, <span style="color: blue;"><b>if an "incidentaloma" is discovered while some imaging test is done for another purpose, this result should simply be ignored</b></span>. Otherwise you risk biopsy or surgery for no reasonable expectation of benefit.</span></div>
<div class="MsoNormal">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: 'Trebuchet MS', sans-serif;">COMMENT: I have been citing examples of these kinds of problems for years, but Dr. Welch puts them all together in one easy to read book with tables and diagrams that makes this otherwise dense information very accessible. While he makes a clear case that our traditional (and rather frivolous) approach to screening and diagnosis for these diseases poses significant hazards to your health, he provides less guidance on another approach to health promotion and disease avoidance other than better consumer information. Here is where my approach to prevention through the "<b><span style="color: #38761d;">Formula for Health</span></b>" really shines.</span></div>
<div class="MsoNormal">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;">Adopting the 5 simple health habits identified in the "<b><span style="color: #38761d;">Formula for Health</span></b>" has been shown in 13 major observational studies and 1 randomized controlled trial to be associated with benefits of the magnitude illustrated in the second poster. <span style="color: blue;"><b>This approach requires no screening test, no blood testing or imaging, and creates no risk of overdiagnosis</b></span>. In fact, it represents the maximum that you can do to improve your overall health. The problem with our modern medical technology is that "overdiagnosis" (with subsequent treatment without benefit) has become a bigger problem than the diseases they were designed to avoid. We have to find another way. A healthy lifestyle (The Formula for Health) is this way.</span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><b><u>References</u></b>:</span></div>
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<a href="http://www.amazon.com/Overdiagnosed-Making-People-Pursuit-Health/dp/0807021997/ref=sr_1_1?s=books&ie=UTF8&qid=1335290331&sr=1-1" style="color: #996633; text-decoration: none;"><br class="Apple-interchange-newline" /><img alt="Product Details" class="productImage" src="http://ecx.images-amazon.com/images/I/51ZSZqIhLZL._SL160_PIsitb-sticker-arrow-dp,TopRight,12,-18_SH30_OU01_AA160_.jpg" style="border-bottom-width: 0px; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; height: 160px; width: 160px;" /></a></div>
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<h3 class="title" style="font-size: 14px; font-weight: normal; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 6px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">
<a class="title" href="http://www.amazon.com/Overdiagnosed-Making-People-Pursuit-Health/dp/0807021997/ref=sr_1_1?s=books&ie=UTF8&qid=1335290331&sr=1-1" style="color: #996633; font-size: 15px; font-weight: bold; text-decoration: none;">Overdiagnosed: Making People Sick in the Pursuit of Health</a> <span class="ptBrand">by <a href="http://www.amazon.com/H.-Gilbert-Welch/e/B001IXS9L0/ref=sr_ntt_srch_lnk_1?qid=1335290331&sr=1-1" style="color: #996633; text-decoration: none;">H. Gilbert Welch</a>, Lisa Schwartz and Steve Woloshin</span> <span class="bindingAndRelease">(Jan 3, 2012)</span></h3>
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(<a class="longReview" href="http://www.amazon.com/Overdiagnosed-Making-People-Pursuit-Health/product-reviews/0807021997/ref=sr_1_1_cm_cr_acr_txt?ie=UTF8&showViewpoints=1" style="color: #996633; text-decoration: none;">44 customer reviews</a>)</div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com1tag:blogger.com,1999:blog-340176576888120508.post-59697377322857880162012-04-11T12:33:00.001-07:002012-04-11T15:40:54.362-07:00WHAT DO YOU KNOW ABOUT CANCER?<div style="text-align: center;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b>A VIEW FROM THE OFFICE</b></span></div><div style="text-align: center;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b><br />
</b></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_NgUKHA15B3ARJC-YfwhbtXngqtVbSP62F3SBHCpam_5N_Lt8ME1XSSPLj8d45thDhvqzbNucltY5nChFLEsa3XTTQ2KCn6PWIsKrt12m8ILA3OLssLUAdhAOaasaNOz8Udm1XtjPB68/s1600/Portola+downtown.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_NgUKHA15B3ARJC-YfwhbtXngqtVbSP62F3SBHCpam_5N_Lt8ME1XSSPLj8d45thDhvqzbNucltY5nChFLEsa3XTTQ2KCn6PWIsKrt12m8ILA3OLssLUAdhAOaasaNOz8Udm1XtjPB68/s320/Portola+downtown.jpg" width="320" /></a></div><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
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<div style="text-align: center;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b>WHAT DO YOU KNOW ABOUT CANCER?</b></span></div><div style="text-align: center;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b><br />
</b></span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b> </b>Last week I wrote about the limited knowledge that most physicians have about cancer incidence, survival rates, and the effects of screening tests. <span style="color: #073763;"><b>Numerous studies indicate that a majority of patients base their decisions to be screened on their doctors' advice</b></span>. Unfortunately, if doctors don't know much, your decision won't be very good. <span style="color: #073763;"><b>The only way to correct this is to try to know a little bit more about cancer yourself.</b></span> So what do you need to know to make good cancer risk assessments and screening decisions?</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"> You need to know some basic epidemiologic facts about each type of cancer. In the old days, this information used to be hard to come by, but now it's all available instantly with a simple Google search. Let's consider several of the major cancers that people often get screened for. Here is a table that lists the core information you would like to know in order to make a decision on testing.</span> </div><div class="MsoNormal"><br />
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</o:p></div><table align="left" border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; margin-left: 6.75pt; margin-right: 6.75pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-table-anchor-horizontal: margin; mso-table-anchor-vertical: margin; mso-table-left: left; mso-table-lspace: 9.0pt; mso-table-rspace: 9.0pt; mso-table-top: 24.0pt; mso-yfti-tbllook: 1184;"><tbody>
<tr> <td style="border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt;"><b><span style="font-size: 12pt;"><span style="font-family: Arial, Helvetica, sans-serif;">Type of cancer<o:p></o:p></span></span></b></div></td> <td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt;"><b><span style="font-size: 12pt;"><span style="font-family: Arial, Helvetica, sans-serif;">Incidence <o:p></o:p></span></span></b></div></td> <td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt;"><b><span style="font-size: 12pt;"><span style="font-family: Arial, Helvetica, sans-serif;">Test: % of negative test results that are true<o:p></o:p></span></span></b></div></td> <td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt;"><b><span style="font-size: 12pt;"><span style="font-family: Arial, Helvetica, sans-serif;">Test: % of positive test results that are false<o:p></o:p></span></span></b></div></td> <td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt;"><b><span style="font-size: 12pt;"><span style="font-family: Arial, Helvetica, sans-serif;">Reduction in relative risk of dying of this cancer after testing.<o:p></o:p></span></span></b></div></td> <td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt;"><b><span style="font-size: 12pt;"><span style="font-family: Arial, Helvetica, sans-serif;">Effect of testing on chances of being alive in 10 years.</span><o:p></o:p></span></b></div></td> </tr>
<tr> <td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt;"><b><span style="font-family: Arial, Helvetica, sans-serif;">Breast cancer<o:p></o:p></span></b></div></td> <td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt;"><span style="font-family: Arial, Helvetica, sans-serif;">3 in 100 for each decade after 50 in average risk women</span></div></td> <td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt;"><span style="font-family: Arial, Helvetica, sans-serif;">Mammogram: 90%</span></div></td> <td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt;"><span style="font-family: Arial, Helvetica, sans-serif;">Mammogram: 2% (each time)</span></div></td> <td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt;"><span style="font-family: Arial, Helvetica, sans-serif;">16% with serial testing every 2 years</span></div></td> <td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt;"><span style="font-family: Arial, Helvetica, sans-serif;">0</span></div></td> </tr>
<tr> <td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt;"><b><span style="font-family: Arial, Helvetica, sans-serif;">Colon cancer<o:p></o:p></span></b></div></td> <td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt;"><span style="font-family: Arial, Helvetica, sans-serif;">57/100,000 in men at age 50; 150/100,000 at age 80.</span></div></td> <td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt;"><span style="font-family: Arial, Helvetica, sans-serif;">Stool blood test: 30%</span></div></td> <td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;"><span style="font-family: Arial, Helvetica, sans-serif;">2%</span></div></td> <td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt;"><span style="font-family: Arial, Helvetica, sans-serif;">15% with annual testing</span></div></td> <td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;"><span style="font-family: Arial, Helvetica, sans-serif;">0</span></div></td> </tr>
<tr> <td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt;"><b><span style="font-family: Arial, Helvetica, sans-serif;">Prostate cancer<o:p></o:p></span></b></div></td> <td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt;"><span style="font-family: Arial, Helvetica, sans-serif;">8 in 100 at age 50; 37 in 100 at age 70</span></div></td> <td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt;"><span style="font-family: Arial, Helvetica, sans-serif;">PSA: 80% (for result > 4)</span></div></td> <td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;"><span style="font-family: Arial, Helvetica, sans-serif;">6% </span></div></td> <td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;"><span style="font-family: Arial, Helvetica, sans-serif;">0</span></div></td> <td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 79.8pt;" valign="top" width="106"><div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;"><span style="font-family: Arial, Helvetica, sans-serif;">0</span></div></td> </tr>
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</div><div> <span style="font-family: 'Trebuchet MS', sans-serif;">If you are considering having a test for cancer, you want to know, first, <span style="color: #073763;"><b>How common is this type of cancer in persons like me?</b></span> You also want to know <span style="color: #073763;"><b>what test are they using</b></span> and <span style="color: #073763;"><b>how good is this test</b></span>. The effectiveness of such tests are rated and compared by telling you how reliable a finding of a <b>negative result</b> is (i.e., How much confidence can you place in a negative test result indicating that you do not have this kind of cancer?) and the chances of having a <b>positive test result</b> that is not due to cancer. The simple fact is that <span style="color: #990000;"><b>no test rules out your chance of having cancer by 100%</b></span>, and <span style="color: #990000;"><b>all tests have a number of false positive results that cause much anxiety but no disease</b></span>. Finally, you want to know that there have been studies done to assess this screening technique and that it does in fact, after a number of years, reduce your chance of getting one of these cancers.</span></div><div><span style="font-family: 'Trebuchet MS', sans-serif;"> In the table above we see that for an <u>average</u> woman, <span style="color: #073763;"><b>her risk of being diagnosed with breast cancer over any 10-year period after age 50 is about 3%</b></span>. If she gets a mammogram regularly (at least every 2 years), she can reduce this risk by about 16%; that is, <span style="color: #073763;"><b>after testing, her risk for a 10-year period will be 2.5%</b></span>. This has to be compared to the risk of <span style="color: #990000;"><b>a false positive test result, which occurs in 2% for every mammogram performed</b></span>; if you get several mammograms (e.g., the screening program calls for at least 10), then your risk of a false positive result is multiplied, and is 20% over 20 years if you get 10 mammograms. <span style="color: #073763;"><b>Each woman has to decide for herself whether she can accept this relatively high risk of a false-positive result in comparison to the relatively small benefit (2.5% absolute risk reduction over 20 years)</b></span>. Finally, every one undergoing any cancer screening test has to be aware that getting all the recommended tests is <span style="color: #073763;"><b>likely </b></span>(but not guaranteed--note the result for prostate cancer screening with a PSA test) <span style="color: #073763;"><b>to offer a lower risk of dying of this type of cancer</b></span>, <span style="color: #990000;"><b>but will, in fact, not insure that you live any longer overall than a person who does not get the screening test</b></span>. In technical language, this means that there is<span style="color: #990000;"><b> no reduction in "all-cause mortality" for any of the common cancer screening tests</b></span>.</span></div><div><span style="font-family: 'Trebuchet MS', sans-serif;"> For women considering having a mammogram they should be aware that <span style="color: #073763;"><b>very recent studies have suggest that that absolute reduction in deaths from breast cancer is reduced by only 1 person per 2000 by screening</b></span>, and <span style="color: #990000;"><b>the chance of having a cancer incorrectly diagnosed and treated is around 20-25%</b></span>. </span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"> A group of widely respected medical experts (the Cochrane Collaboration folks) have put together a nice summary of the basic facts needed to make the breast cancer screening decision--"<i><b><a href="http://www.cochrane.dk/" target="_blank">What you always wanted to know about breast screening</a></b></i>". </span></div><div><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div><span style="font-family: 'Trebuchet MS', sans-serif;"> Colon cancer screening poses the problems that the disease is considerably <span style="color: #990000;"><b>rarer </b></span>than breast cancer (only about 50 cases per 100,000 persons at age 50, increasing to about 150 cases per 100,000 by age 80), that the <span style="color: #990000;"><b>test (stool testing for blood) is not very good</b></span> (it reliably detects only about 30% of actual cancers, and gives a <span style="color: #990000;"><b>false positive result in 2%</b></span> of persons tested every time it is used; this is a lot when you screen a large population. For example, if 100,000 persons were screened at age 50, there would be 57 true positive tests, and 2000 false positive tests). All of these false positive results have to be evaluated with additional testing (colonoscopy). The final disadvantage is that people just don't like having the necessary follow-up test for a positive result (the colonoscopy), which requires a full day of bowel preparation (total bowel wash-out) and a full-day lost from work or home on the day of the test, since sedation is used.</span></div><div><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div><span style="font-family: 'Trebuchet MS', sans-serif;"> Prostate cancer screening is the most curious case since there really is <span style="color: #990000;"><b>no good evidence that the test reduces even your relative risk of dying of prostate cancer</b></span> because this disease is so common in men and often just sits there for many years without causing any problem at all.</span></div><div><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div><span style="font-family: 'Trebuchet MS', sans-serif;"> So this is the summary of the kind of basic information you should know before undergoing any cancer screening test. <span style="color: #073763;"><b>Because there are so many studies demonstrating that most physicians do not actually know or understand these facts, I am afraid I have to suggest that you look them up yourself</b></span>.</span></div><div><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: center;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b>THE PROBLEM OF BIAS</b></span></div><div style="text-align: center;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b><br />
</b></span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b> </b>Above I have discussed <span style="color: #073763;"><b>the real risks</b></span> of getting these cancers and your chances of living longer, if you are diagnosed with one. The truth, however, is that most people (including both physicians and consumers) are not driven primarily by the real risks. They are driven by <span style="color: #073763;"><b>perceived risk</b></span>--something tantamount to a gut feeling that one is likely to get such a cancer and this risk can be abated or avoided by a screening test. To illustrate how much of a problem the overperception of risk is, consider this chart from a 2010 publication.(1)</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyHlRazvIvT8sbzah_q-ZIubgWbpFS1bwsXxA3E_exyeweizVkXbWYDARTizIXCIHG34HOgoKifj0TL2md8kDHpCuIr4nNDVZgKtqEqEyjxbIty4xfO-BEmzxHaExxZTVEINt2iD5XEtQ/s1600/Cancer+risk+perceptions.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="302" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyHlRazvIvT8sbzah_q-ZIubgWbpFS1bwsXxA3E_exyeweizVkXbWYDARTizIXCIHG34HOgoKifj0TL2md8kDHpCuIr4nNDVZgKtqEqEyjxbIty4xfO-BEmzxHaExxZTVEINt2iD5XEtQ/s640/Cancer+risk+perceptions.JPG" width="640" /></a></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"> For purposes of this graphic, you are a "<b>participant</b>." What the chart shows is the risk of dying of each cancer and the risk of being diagnosed with each cancer as estimated by the "participants" in a screening program compared to the actual risks as demonstrated by epidemiological studies (SEER). The <b><span style="color: #666666;">dark gray bar</span></b> shows participants estimates of their chance of dying of each cancer, if they have it, and <b>the black bar</b> shows their estimate of their chances of getting each cancer. Compared to the actual risks demonstrated in studies, <span style="color: #990000;"><b>participants tend to dramatically overestimate their risk both of getting these diseases and of dying from the disease, if they do get it. This fact then induces them to undergo testing whether or not the testing is in fact very effective.</b></span></span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"> As I showed in my last blog, physicians are prone to very similar biases. They are inappropriately influenced in favor of testing by reported increases in "<b>5-year survival</b>" even though this means nothing about the actual effectiveness of a test. More than half of physicians are not aware that screening will always lead to an apparent increase in "5-year survival" (because cancers are detected earlier) that does not necessarily imply any reduction in mortality at all. While "5-year survival" is a critically important measure for different treatments for diagnosed cancers, it has no relevance to the assessment of screening effectiveness; a majority of physicians do not know this and will provide inappropriate endorsements of screening tests when told that 5-year survival was noted to increase after starting a screening program. In the referenced study below, only 1 of 65 physicians was aware that screening consistently leads to "overdiagnosis"--imputing a diagnosis of cancer to someone who was never at risk of dying from it.</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"> <span style="color: #073763;"><b>So what's the bottom line in cancer screening? </b></span>There are really <b>only two facts you want to know</b>. First, <span style="color: #073763;"><b>what is the absolute reduction in your risk of dying of a cancer for which you have been screened?</b></span></span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">For some common cancers, here are these numbers:</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b><u>Breast cancer</u></b>: The absolute reduction in risk of dying from breast cancer through screening is 1 per 2000.</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b><u>Colon cancer</u></b>: The absolute reduction in the risk of dying of colon cancer through screening at age 50 is about 10 cases per 100,000 persons screened. For persons being screened at age 70, the absolute reduction in the risk of dying is about 25 per 100,000 persons screened.</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b><u>Prostate cancer</u></b>: The absolute reduction in the risk of dying of prostate cancer through screening is 0.</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b><u>Cervical cancer</u></b>: The absolute reduction in the risk of dying of cervical cancer through screening with Pap smears is 3 per 100,000.</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b><u>Melanoma</u></b>: There is no evidence that screening programs reduce the absolute risk of dying from melanoma.</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">The other fact you want to know is, <span style="color: #073763;"><b>What is your chance of actually living longer due to undergoing these screening tests?</b></span> Here are the relevant numbers:</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b><u>Breast cancer</u></b>: There is no increase in your total expected lifespan from breast cancer screening with mammography.</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b><u>Colon cancer</u></b>: There is no increase in your total expected lifespan from colon cancer screening with either the fecal blood test or colonoscopy.</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b><u>Prostate cancer</u></b>: There is no increase in your total expected lifespan from prostate cancer screening with the PSA test.</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b><u>Cervical cancer</u></b>: There is no increase in your total expected lifespan from cervical cancer screening with Pap smears.</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b><u>Melanoma</u></b>: There is no increase in your total expected lifespan from melanoma screening of the skin.</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"> Well, those are the facts. Now you can make your decision.</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
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</span></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">References: Hoffman RM et al. Decision-making processes for breast, colorectal, and prostate cancer screening: results from the DECISIONS study. Med Decis Making 2010; 30(5 Suppl(): 53S-64S. doi: 10.1177/0272989X10378701</span></div><div><span style="font-family: 'Trebuchet MS', sans-serif;"> </span></div>Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com2tag:blogger.com,1999:blog-340176576888120508.post-20212392008681947552012-04-03T11:59:00.002-07:002012-04-09T08:29:45.468-07:00What Doctors Don't Know about Cancer Screening and You Should!<div style="text-align: center;"><b><span style="font-family: "Trebuchet MS", sans-serif;">A VIEW FROM THE OFFICE</span></b></div><div style="text-align: center;"><b><span style="font-family: "Trebuchet MS", sans-serif;"><br />
</span></b></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgnCaJNHSrdFCFgwtGH__IlHQe-HiXddCy4qh6I7MYZpnVqUwtZCD-KyrAi9SU4lf3rjS3R1gXRr78hyPPvRgEcyf3LTETzcNAwCl7O_pgGHy3ERGwOwBoGJRjtQBe1Z1MIUp8ul1jL9oY/s1600/Portola+office.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgnCaJNHSrdFCFgwtGH__IlHQe-HiXddCy4qh6I7MYZpnVqUwtZCD-KyrAi9SU4lf3rjS3R1gXRr78hyPPvRgEcyf3LTETzcNAwCl7O_pgGHy3ERGwOwBoGJRjtQBe1Z1MIUp8ul1jL9oY/s320/Portola+office.JPG" width="320" /></a></div><div style="text-align: center;"><b><span style="font-family: "Trebuchet MS", sans-serif;"><br />
</span></b></div><div style="text-align: center;"><b><span style="font-family: "Trebuchet MS", sans-serif;">WHAT DOCTORS DON'T KNOW ABOUT CANCER SCREENING </span></b></div><div style="text-align: center;"><b><span style="font-family: "Trebuchet MS", sans-serif;">AND YOU SHOULD!</span></b></div><div style="text-align: center;"><b><span style="font-family: "Trebuchet MS", sans-serif;"><br />
</span></b></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"><b> </b>Here are a few examples of results from cancer screening studies. See what you think.</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;">#1: The lung cancer example: "Imagine a group of patients in whom cancer was diagnosed because of symptoms at age 67 years, all of whom die at age 70 years. Each patient survives only 3 years, so the 5-year survival for the group is 0%. Now imagine that the same group undergoes screening. Screening tests by definition lead to earlier diagnosis. Suppose that with screening, cancer is diagnosed in all patients at age 60 years, but they nevertheless die at age 70 years. In this scenario, each patient survives 10 years, so the 5-year survival for the group is 100%." Sounds better, doesn't it? But it's not. "Yet, despite this dramatic improvement in survival rate (from 0% to 100%), nothing has changed about how many people die or when."</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;">#2: The breast cancer example: "[E]ven for mammography screening for breast cancer..., several analyses have demonstrated that the vast majority of women with screen-detected breast cancer have not had their lives saved by screening, but rather have been diagnosed early with no change in outcome or have been overdiagnosed [i.e., diagnosed with a cancer that was never going to do any harm]."</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;">#3: The prostate cancer example: In a survey among practicing physicians, the authors of this report used actual data from prostate cancer screening studies but just referred to the condition as 'Disease X'. They asked the physician respondents to assume that the tests used for screening were noninvasive, free, and detected cases of cancer for which treatment, such as surgery, exists. The effect of the test was described in terms of 5-year survival, and, in another scenario, the effect of the same test for 'Disease Z' was described by showing its effect on the death rate from this cancer.</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"> The result for the test for disease X was described as showing a 68% survival rate without screening and a 99% survival rate with screening.</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"> The result for the test for disease Z was described as resulting in 2 deaths per 1000 persons without screening vs. 1.6 deaths per 1000 persons with screening.</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"> Remember, both of these results apply to prostate cancer. They are just different ways of looking at the same data. Which result appears better to you?</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"> The key here is that earlier screening will ALWAYS detect more cases, and more early cases, but this fact in and of itself does not imply any improved outcome. Improved outcomes need to be determined by randomized controlled clinical trials.</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"> In this example, the second way of looking at the result is actually the superior method. It shows that there is a small, but statistically significant difference in mortality, associated with the screening intervention. But what you don't know yet is whether there are any harms from the screening intervention. This is a particularly important question because the mortality benefit is so small (0.4 cases per 1000); any adverse effects might quickly outweigh that benefit. </span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"> The example in the survey went on to explain that earlier screening for prostate cancer ultimately resulted in an incidence of 46 cases per 1000 persons with screening vs. only 27 cases per 1000 persons without screening. Since the mortality benefit is only 0.4 deaths per 1000 subjects, these data mean that 19 extra persons will be diagnosed with prostate cancer without receiving any mortality benefit. Thus they will go through biopsies, chemotherapy, surgeries, and complications of surgery including impotence and incontinence. Now think about it. If it was your life, would you want this test? It is precisely because of this problem that the <b>United States Preventive Services Task Force</b> (our national experts) recommended against any screening for prostate cancer with our currently available tests.</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"> Now let's look a little further at how the physicians in this survey interpreted the data they were given.</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;">1. The primary care physicians demonstrated limited knowledge of what evidence might prove that a cancer screening test saves lives. <b><span style="color: red;">About one half (47%) incorrectly said that finding more cancer cases in screened as opposed to unscreened populations provided such proof. </span></b></span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;">2. <b><span style="color: red;">Many physicians did not distinguish between irrelevant evidence for screening (e.g., improved survival rates) and relevant evidence (reduced cancer mortality)</span></b>: Nearly as many physician incorrectly believed that survival data proved that screening saves lives (76%) as believed that mortality data provide this proof (81%).</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;">3. <b><span style="color: red;">80% of physicians said that the screening test supported by irrelevant evidence (5-year survival increased from 68% to 99%) 'saves lives from cancer,'</span></b> whereas only 60% said this about the test supported by relevant evidence (cancer mortality reduced from 2 to 1.6 in 1000 persons.</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;">4. Physicians were also <b><span style="color: red;">three times more likely to say they would 'definitely recommend' the test that improved 5-year survival compared with the one that reduced cancer mortality (69% vs 23%)</span></b>.</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;">5. After seeing the data on the test that improved 5-year survival, physicians were then shown how the screening test increased the proportion of cases of cancer detected at Stage I (from 36% without screening to 54% with screening). This information in fact provides little support for a screening test because even a harmful test--one that increased mortality--could increase detection of early-stage cancer. <b><span style="color: red;">Nonetheless, 68% of physicians said this information made them 'more' or 'much more' likely to recommend the test</span></b>. In addition, 57% now expected the screening to save more lives from cancer than they had initially estimated without this additional information.</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;">6. After seeing the data on the test that reduced mortality, physicians were shown how the screening test increased cancer incidence (from 27 to 46 per 1000 persons over 5 years). <b><span style="color: red;">62% of physicians said the increased incidence made them 'more' or 'much more' likely to recommend the test. In fact, 50% now expected the screening to save even more lives from cancer even thought the increased incidence is irrelevant to mortality</span></b>. Overall, 11% incorrectly endorsed the explanation that the 'screened group must have had more cancer risk factors.' 42% incorrectly believed that the 'decreased mortality is all the more impressive given the higher incidence' with screening. More than one half (58%) did not endorse the statement that "For every death prevented by screening, some people are diagnosed and treated with cancer Z unnecessarily..."</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;">7. At the end of the scenario about the test that improved survival, physicians were presented with an explanatory note explaining that higher survival (or finding more cases of state I cancer) with screening does not prove that screening saves lives and that such proof can come only from a randomized trial demonstrating lower cancer mortality. Although 76% stated that they found the note helpful,<b><span style="color: red;"> it had an inconsistent effect; 29% said it made them more likely to recommend the screening test, and 21% said it made them less likely.</span></b></span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"><br />
</span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;">8. At the end of the scenario about the test that reduced cancer mortality and increased incidence, physicians were presented with an explanatory note that highlighted the possibility of over-diagnosis (that is, to prevent 1 death from cancer, as many as 47 additional people would be diagnosed unnecessarily). 80% found this note helpful, and 40% said it made them less likely to recommend the new test. <b><span style="color: red;">However, 23% said it made them more likely to recommend the test. </span></b></span></div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;"><br />
</span></div><div style="text-align: left;"><div class="MsoNormal" style="margin-bottom: 0pt;"><span style="font-family: "Trebuchet MS", "sans-serif"; font-size: 12pt;">Now here is the way I like to express the relative effectiveness of cancer screening. I use it as a test for students and residents regularly. It is simple. <b>Just review the following table</b> for the most commonly recommended screening tests for cancer.</span></div><div align="center" class="MsoNormal" style="margin-bottom: 0pt; text-align: center;"><span style="font-family: "Times New Roman", serif;"><br />
</span></div><div class="MsoNormal" style="margin-bottom: 0pt;"><br />
</div><table border="1" cellpadding="0" cellspacing="1" class="MsoNormalTable" style="background-clip: initial; background-color: #999999; background-origin: initial; width: 650px;"><tbody>
<tr><td style="padding-bottom: 0.75pt; padding-left: 0.75pt; padding-right: 0.75pt; padding-top: 0.75pt;"><div class="MsoNormal" style="margin-bottom: 0pt; text-align: center;"><b><span style="font-family: "Arial", "sans-serif"; font-size: 12pt;">Cancer Type</span></b><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"></span></div></td><td style="padding-bottom: 0.75pt; padding-left: 0.75pt; padding-right: 0.75pt; padding-top: 0.75pt;"><div class="MsoNormal" style="margin-bottom: 0pt; text-align: center;"><b><span style="font-family: "Arial", "sans-serif"; font-size: 12pt;">Relative Risk Reduction</span></b><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"></span></div></td><td style="padding-bottom: 0.75pt; padding-left: 0.75pt; padding-right: 0.75pt; padding-top: 0.75pt;"><div class="MsoNormal" style="margin-bottom: 0pt; text-align: center;"><b><span style="font-family: "Arial", "sans-serif"; font-size: 12pt;">Reduction in All-Cause Mortality</span></b></div></td></tr>
<tr><td style="padding-bottom: 0.75pt; padding-left: 0.75pt; padding-right: 0.75pt; padding-top: 0.75pt;"><div class="MsoNormal" style="margin-bottom: 0pt; text-align: center;"><b><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"> Breast</span></b><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"></span></div></td><td style="padding-bottom: 0.75pt; padding-left: 0.75pt; padding-right: 0.75pt; padding-top: 0.75pt;"><div class="MsoNormal" style="margin-bottom: 0pt; text-align: center;"><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"> 16% (USPSTF)</span></div></td><td style="padding-bottom: 0.75pt; padding-left: 0.75pt; padding-right: 0.75pt; padding-top: 0.75pt;"><div class="MsoNormal" style="margin-bottom: 0pt; text-align: center;"><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"> 0%</span></div></td></tr>
<tr><td style="padding-bottom: 0.75pt; padding-left: 0.75pt; padding-right: 0.75pt; padding-top: 0.75pt;"><div class="MsoNormal" style="margin-bottom: 0pt; text-align: center;"><b><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"> Colon</span></b><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"></span></div></td><td style="padding-bottom: 0.75pt; padding-left: 0.75pt; padding-right: 0.75pt; padding-top: 0.75pt;"><div class="MsoNormal" style="margin-bottom: 0pt; text-align: center;"><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"> 15% (USPSTF)</span></div></td><td style="padding-bottom: 0.75pt; padding-left: 0.75pt; padding-right: 0.75pt; padding-top: 0.75pt;"><div class="MsoNormal" style="margin-bottom: 0pt; text-align: center;"><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"> 0%</span></div></td></tr>
<tr><td style="padding-bottom: 0.75pt; padding-left: 0.75pt; padding-right: 0.75pt; padding-top: 0.75pt;"><div class="MsoNormal" style="margin-bottom: 0pt; text-align: center;"><b><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"> Cervical</span></b><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"></span></div></td><td style="padding-bottom: 0.75pt; padding-left: 0.75pt; padding-right: 0.75pt; padding-top: 0.75pt;"><div class="MsoNormal" style="margin-bottom: 0pt; text-align: center;"><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"> 40-60% (USPSTF)</span></div></td><td style="padding-bottom: 0.75pt; padding-left: 0.75pt; padding-right: 0.75pt; padding-top: 0.75pt;"><div class="MsoNormal" style="margin-bottom: 0pt; text-align: center;"><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"> 0%</span></div></td></tr>
<tr><td style="padding-bottom: 0.75pt; padding-left: 0.75pt; padding-right: 0.75pt; padding-top: 0.75pt;"><div class="MsoNormal" style="margin-bottom: 0pt; text-align: center;"><b><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"> Prostate</span></b><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"></span></div></td><td style="padding-bottom: 0.75pt; padding-left: 0.75pt; padding-right: 0.75pt; padding-top: 0.75pt;"><div class="MsoNormal" style="margin-bottom: 0pt; text-align: center;"><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"> unknown (studies inconclusive)</span></div></td><td style="padding-bottom: 0.75pt; padding-left: 0.75pt; padding-right: 0.75pt; padding-top: 0.75pt;"><div class="MsoNormal" style="margin-bottom: 0pt; text-align: center;"><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"> 0%</span></div></td></tr>
<tr><td style="padding-bottom: 0.75pt; padding-left: 0.75pt; padding-right: 0.75pt; padding-top: 0.75pt;"><div class="MsoNormal" style="margin-bottom: 0pt; text-align: center;"><b><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"> Skin</span></b><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"></span></div></td><td style="padding-bottom: 0.75pt; padding-left: 0.75pt; padding-right: 0.75pt; padding-top: 0.75pt;"><div class="MsoNormal" style="margin-bottom: 0pt; text-align: center;"><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"> unknown (studies inconclusive)</span></div></td><td style="padding-bottom: 0.75pt; padding-left: 0.75pt; padding-right: 0.75pt; padding-top: 0.75pt;"><div class="MsoNormal" style="margin-bottom: 0pt; text-align: center;"><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"> 0%</span></div></td></tr>
</tbody></table><div class="MsoNormal" style="margin-bottom: 0pt;"><br />
</div><div class="MsoNormal" style="margin-bottom: 0pt;"><b><span style="font-family: "Trebuchet MS", "sans-serif"; font-size: 12pt;"> </span></b><span style="font-family: "Trebuchet MS", "sans-serif"; font-size: 12pt;"> The "relative risk reduction" means that with the screening test for cancer X your risk of dying of cancer X is reduced by this amount; thus breast cancer screening reduces your risk of dying of breast cancer by about 16%. What "<b>Reduction in All-Cause Mortality</b>" means is how many people are still alive at the end of a given period of time. What the number "0" indicates is that, when you consider all possible causes of death, NO ONE appears to be living any longer as a result of cancer screening. </span></div><div class="MsoNormal" style="margin-bottom: 0pt;"><span style="font-family: "Trebuchet MS", "sans-serif"; font-size: 12pt;"> Again, what this means is that for all our trouble <b><span style="color: #102885;">no one, I mean, <i>No one!</i>, is living any longer when you look at all possible causes of death.</span></b> Yes, they are having somewhat fewer deaths from breast, colon, and cervical cancer (if they comply with screening recommendations), but they are not living one single day longer. You have just rearranged the desk chairs on the Titanic.</span><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"></span></div><div class="MsoNormal" style="margin-bottom: 0pt;"><br />
</div><div class="MsoNormal" style="margin-bottom: 0pt;"><span style="font-family: "Trebuchet MS", "sans-serif"; font-size: 12pt;"> Most significant from this table, since no single cancer screening strategy reduces all-cause mortality at all, is its clear implication: <b><span style="color: #102885;">IF YOU CAN FIND ANY INTERVENTION THAT LEADS TO EVEN A 1-2% REDUCTION IN ALL-CAUSE MORTALITY, IT WILL DO FAR, FAR MORE GOOD THAN ALL OF THESE CANCER SCREENING INTERVENTIONS PUT TOGETHER!</span></b></span><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"></span></div><div class="MsoNormal" style="margin-bottom: 0pt;"><br />
</div><div class="MsoNormal" style="margin-bottom: 0pt;"><span style="font-family: "Trebuchet MS", "sans-serif"; font-size: 12pt;"> Thus, the further question to ask is: <b><span style="color: #102885;">Do we have any such interventions that will reduce all-cause mortality?</span></b> And I have to say, <b><span style="color: #0c850c;">"Of course, we do." Let's encourage a healthy lifestyle with our <i><u>Formula for Health</u></i>.</span></b> Based on the 14 major observational studies of healthy lifestyle we can impute the following benefits to those who adopt all 5 healthy habits:</span><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjzABfrvondgZja_3SYLNEwgb27-Bm5vbNvpCiupbxXJ5576TCI53K-vUjv4LAwu-OifTNWxjy6szhmGxegI1zn66nNqa74AmcX9o6QLAD-cUtF_Ls1IsZ1hIeSe6li6gvxbA3qfs5YEFk/s1600/Formula+-+Benefits+list+color.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjzABfrvondgZja_3SYLNEwgb27-Bm5vbNvpCiupbxXJ5576TCI53K-vUjv4LAwu-OifTNWxjy6szhmGxegI1zn66nNqa74AmcX9o6QLAD-cUtF_Ls1IsZ1hIeSe6li6gvxbA3qfs5YEFk/s640/Formula+-+Benefits+list+color.jpg" width="494" /></a></div><div class="MsoNormal" style="margin-bottom: 0pt;"><b><span style="font-family: "Trebuchet MS", "sans-serif"; font-size: 12pt;"> <span style="color: #102885;">This lifestyle strategy could reduce your overall risk of dying (all-cause morality) by 40-65%</span></span></b><span style="font-family: "Trebuchet MS", "sans-serif"; font-size: 12pt;">. The fact that it leads to <b><span style="color: #102885;">36-64% reductions in ALL cancers</span></b> plus a <b><span style="color: #102885;">40-65% reduction in all cause mortality</span></b> means that <b><u><span style="color: #102885;">the adoption or maintenance of a healthy lifestyle is the SINGLE MOST EFFECTIVE THING YOU CAN DO TO REDUCE YOUR PERSONAL RISK OF CANCER</span></u></b>. And it's really pretty easy and inexpensive to promote. Just hand out my pretty little flyers (above) and take a minute or two to talk about it. It beats all the mammograms, FOBTs, sigmoidoscopies, colonoscopies, Pap smears, and colposcopies put together at far, far less cost. What's to think about? This is a no-brainer.</span><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"> </span></div><div class="MsoNormal" style="margin-bottom: 0pt;"><span style="font-family: "Trebuchet MS", "sans-serif"; font-size: 12pt;"> Do something sensible to prevent cancer today!</span><br />
<br />
<span style="font-family: Trebuchet MS;">Here is your strategy:</span><br />
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<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiqO-Ae-CAyS_gHMWj0yBuD7uzpQqREE9f5nNQpOt-eLXSfgDJzYu1v2BDFgRmtP1SkVo3W3Dwqj5HB8DyzSnqfKIY5UQcc_3aUbEiV2g-ls4dOnWwLd-1-zpY4UnfKQif8OAgXU5CRQj4/s1600/Formula+w+data+&+check+marks+EPHC.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="640" nda="true" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiqO-Ae-CAyS_gHMWj0yBuD7uzpQqREE9f5nNQpOt-eLXSfgDJzYu1v2BDFgRmtP1SkVo3W3Dwqj5HB8DyzSnqfKIY5UQcc_3aUbEiV2g-ls4dOnWwLd-1-zpY4UnfKQif8OAgXU5CRQj4/s640/Formula+w+data+&+check+marks+EPHC.jpg" width="484" /></a></div><br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgt-B5ZHBU6K32-ypo-5lnC-ui6hdc3RZd4nCd8DGMm2ecgSZ4oB1oGH52kxi46HleILvuHU3jH-HKsoWfwwRYxXAMe6G6vGPXSs3Sl7i7vUJUNSrInns-SdqSSkvRG93UJ1DKBw-j34z4/s1600/EPHC+Lifestyle+poster+2-sided%255B1%255D_Page_2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" nda="true" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgt-B5ZHBU6K32-ypo-5lnC-ui6hdc3RZd4nCd8DGMm2ecgSZ4oB1oGH52kxi46HleILvuHU3jH-HKsoWfwwRYxXAMe6G6vGPXSs3Sl7i7vUJUNSrInns-SdqSSkvRG93UJ1DKBw-j34z4/s320/EPHC+Lifestyle+poster+2-sided%255B1%255D_Page_2.jpg" width="242" /></a></div></div><div class="MsoNormal" style="margin-bottom: 0pt;"><span style="font-family: "Trebuchet MS", "sans-serif"; font-size: 12pt;"><br />
</span></div><div class="MsoNormal" style="margin-bottom: 0pt;"><span style="font-family: "Trebuchet MS", "sans-serif"; font-size: 12pt;"><br />
</span></div><div class="MsoNormal" style="margin-bottom: 0pt;"><span style="font-family: "Trebuchet MS", "sans-serif"; font-size: 12pt;">ADDENDUM: I will be at the Portola clinic on Saturday, April 4th. I hope to see some of you there.</span></div><div class="MsoNormal" style="margin-bottom: 0pt;"><span style="font-family: "Trebuchet MS", "sans-serif"; font-size: 12pt;"><br />
</span></div><div class="MsoNormal" style="margin-bottom: 0pt;"><span style="font-family: "Trebuchet MS", "sans-serif"; font-size: 12pt;">References:</span></div><div class="MsoNormal" style="margin-bottom: 0pt;"><span style="font-family: "Trebuchet MS", "sans-serif"; font-size: 12pt;"><br />
</span></div><div class="MsoNormal" style="margin-bottom: 0pt;"></div><div class="MsoNormal" style="margin-bottom: 0pt;"><span style="font-family: "Trebuchet MS", "sans-serif"; font-size: 12pt;">1. Wegwarth O et al. Do physicians understand cancer screening statistics? A national survey of primary care physicians in the United States. Ann Intern Med 2012; 156: 340-9.</span></div><div class="MsoNormal" style="margin-bottom: 0pt;"><span style="font-family: "Trebuchet MS", "sans-serif"; font-size: 12pt;"><br />
</span></div><div class="MsoNormal" style="margin-bottom: 0pt;"><span style="font-family: "Trebuchet MS", "sans-serif"; font-size: 12pt;">2. Editorial: What we don't know can hurt our patients: Physician innumeracy and overuse of screening tests. Ann Intern Med 2012; 156: 392-3.</span><span style="font-family: "Times New Roman", "serif"; font-size: 12pt;"></span></div><br />
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</div><div class="MsoNormal" style="margin-bottom: 0pt;"><br />
</div></div>Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com2tag:blogger.com,1999:blog-340176576888120508.post-821504546662279382012-02-28T17:08:00.000-08:002012-02-28T17:08:28.791-08:00<div style="text-align: center;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b>A VIEW FROM THE OFFICE</b></span></div><span style="font-family: 'Trebuchet MS', sans-serif;"><b><br />
</b></span><br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSny7pzoUddD11Kyb9rfX5mSJwfUoF3YqB3j-FqOhLx0KhxbnVOZYCVRdKSsahmnevFqQfk-PLiuOZrlReNsOxW8-n8iduGU4qPA0LI6CT5030PsiyDN8giiFYeJhk_WXJR4cxj5Wc_Tk/s1600/Portola+View+from+the+Office.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSny7pzoUddD11Kyb9rfX5mSJwfUoF3YqB3j-FqOhLx0KhxbnVOZYCVRdKSsahmnevFqQfk-PLiuOZrlReNsOxW8-n8iduGU4qPA0LI6CT5030PsiyDN8giiFYeJhk_WXJR4cxj5Wc_Tk/s320/Portola+View+from+the+Office.jpg" width="320" /></a></div><span style="font-family: 'Trebuchet MS', sans-serif;"><b><br />
</b></span><br />
<div style="text-align: center;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b>HOW DO YOU KNOW IF SOMEONE IS COMPETENT </b></span></div><div style="text-align: center;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b>TO MAKE A DECISION FOR HEALTH CARE</b></span></div><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">The determination of whether someone is competent to make their own decisions is very difficult. Over the last 20 years numerous experts have taken their best shots at designing algorithms or questionnaires to help primary care physicians to make this determination with relatively little success. In this article I am sharing the result of a recent study of the different instruments that have been developed for this.(1) The instrument that has been the best tested and validated is called the "<b>Aid to Capacity Evaluation</b>." A copy of this <a href="http://capm.wikispaces.com/file/view/ACE.pdf" target="_blank">form</a> is available as a free PDF file online and includes instructions for use.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"> My reason for including this information in a consumer blog is because <b><span style="color: #0b5394;">it is often too late to be practical if the family waits for a physician to do the evaluation</span></b>. These kinds of decisions are best anticipated. Most relatives and friends of someone whose health is deteriorating to the point of being unable to make a quality decision for themselves are aware that in some areas of life the patient should not be left on his/her own. Reviewing this form allows family members to walk through the steps to assess the different areas of capacity/competence. Once family members get to the point of thinking this may be helpful, it is time to formally prepare a document expressing the patient's wishes for end-of-life care or other critical health decisions. Ideally, this can be done before the patient becomes incompetent across the board.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"> The legal background for this issue is that <span style="color: #0b5394;"><b>all adult patients (over the age of 18) are presumed by law to be competent</b>.</span> Even if a patient has severe chronic disease, even chronic mental illness like schizophrenia, the initial legal presumption is that they are capable of making their own decisions. In general, psychiatric patients cannot be compelled to take their medications. Psychiatric patients are presumed capable of determining whether they want a surgical procedure or not, even if a "reasonable" person of the same age would reach a different conclusion. They are not required to make the "correct" decision (whatever that is). <b><span style="color: #0b5394;">The decision just needs to reflect a minimal understanding of the problem or issue, a clear and consistent preference (whether logical or not), and not be obviously impaired by other illness, particularly depression or delusions</span></b>. A person with a chronic mental illness such as schizophrenia or dementia can be quite capable of expressing a meaningful decision about a surgical treatment or diagnostic test even when they care clearly incompetent to manage their own finances, hygiene, or usual activities of daily living. So to say a person has dementia, by itself, has no specific implications for their capacity to make medical decisions.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"> <b><span style="color: #0b5394;">An individual can be deprived of their right to make their own decisions only by an authorized police official</span></b> (e.g., for a 5150 Psychiatric hold for 72 hours to perform a formal evaluation of competence and safety) <b><span style="color: #0b5394;">or judicial determination</span></b> (a competency or custodianship hearing). The police action is only a temporary one. The judicial action obviously requires significant time to go through the steps of finding an advocate, reviewing relevant documents and witnesses, and scheduling a formal hearing on the court docket. <b><span style="color: #0b5394;">As a practical matter, the legal system is simply not capable of responding quickly enough to assist in making decisions about an individual's competency to be helpful when it is needed. </span></b>That is why it is so important that family members or anyone who takes part in the care or support of a patient proactively address these issues well in advance of acute illness or the need for something like nursing home placement when the patient says s/he does not want to go.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"> I believe that the form below is very simple and clear to follow. A lay person can walk through the appropriate evaluation process for someone s/he is concerned about.<b><span style="color: #0b5394;"> It is so much better to have this process addressed early in the course of chronic illness, even by a lay person, than it is to wait until the situation is urgent and then try to have a doctor do it.</span></b> Legally a doctor cannot make the determination that someone is not competent to make a decision. If an advance directive is not in place, then the legal process will have to be invoked.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<div style="text-align: center;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b>THE AID TO CAPACITY EVALUATION</b></span></div><br />
<span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;">[Record observations that support your score in each domain, including exact responses of the patient. </span><br />
<span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;">Indicate your score for each domain with a circle.]</span><br />
<span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;"><br />
</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><b>1. Able to understand medical <u>problem </u></b></span><br />
(Sample questions: What problem are you having now? What problem is <br />
bothering you most? Why are you in the hospital? Do you have (name<br />
problem)?) <br />
<br />
<b><span style="font-family: 'Trebuchet MS', sans-serif;">YES NO UNSURE</span></b><br />
<br />
Observations: ______________________________________________ <br />
<br />
__________________________________________________________<br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;"><b>2. Able to understand proposed <u>treatment</u> </b></span><br />
(Sample questions: What is the treatment for [your problem]?<br />
What else can we do to help you? Can you have [proposed treatment]?<br />
<br />
<b><span style="font-family: 'Trebuchet MS', sans-serif;">YES NO UNSURE</span></b> <br />
<br />
Observations: ______________________________________________<br />
_________________________________________________________<br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;"><b>3. Able to understand <u>alternative</u> to proposed treatment (if any)</b></span><br />
(Sample questions: Are there any other [treatments]? What other<br />
options do you have? Can you have [alternative treatment]?<br />
<br />
<b><span style="font-family: 'Trebuchet MS', sans-serif;">YES NO UNSURE UNDISCLOSED</span></b><br />
<b><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></b><br />
Observations: ______________________________________________<br />
<br />
__________________________________________________________<br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;"><b>4. Able to understand <u>option of refusing</u> proposed treatment </b></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><b>(including withholding or withdrawing proposed treatment)</b></span><br />
(Sample questions: Can you refuse [proposed treatment]? Can we stop<br />
[proposed treatment]? <br />
<br />
<b><span style="font-family: 'Trebuchet MS', sans-serif;">YES NO UNSURE</span></b> <br />
<b><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></b><br />
Observations: _____________________________________________<br />
_________________________________________________________<br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;"><b>5. Able to appreciate reasonably <u>foreseeable consequences</u> of</b></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><b> accepting proposed treatment</b></span><br />
(Sample questions: What could happen to you if you have [proposed<br />
treatment]? Can [proposed treatment] cause problems/side effects?<br />
Can [proposed treatment] help you live longer? )<br />
<br />
<b><span style="font-family: 'Trebuchet MS', sans-serif;">YES NO UNSURE</span></b> <br />
<b><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></b><br />
Observations: _____________________________________________<br />
_________________________________________________________<br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;"><b>6. Able to appreciate reasonable foreseeable <u>consequences </u>of </b></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><b>refusing proposed treatment (including withholding or </b></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><b>withdrawing proposed treatment) </b></span><br />
(Sample questions: What could happen to you if you don't have [proposed <br />
treatment]? Could you get sicker/die if you don't have [proposed treatment]? <br />
What could happen if you have [alternative treatment]? (If alternatives are available) <br />
<br />
<b><span style="font-family: 'Trebuchet MS', sans-serif;">YES NO UNSURE</span></b> <br />
<b><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></b><br />
Observations: _____________________________________________<br />
_________________________________________________________<br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">(Note: for questions 7a and 7b, a “yes” answer means the person’s decision is affected by depression.)</span><br />
<br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;"><b>7a. The person's decision is affected by depression</b></span><br />
(Sample questions: Can you help me understand why you've decided to<br />
accept/refuse treatment? Do you feel that you're being punished? Do<br />
you think you're a bad person? Do you have any hope for the future?<br />
Do you deserve to be treated? )<br />
<br />
<b><span style="font-family: 'Trebuchet MS', sans-serif;">YES NO UNSURE</span></b> <br />
<b><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></b><br />
Observations: _____________________________________________<br />
_________________________________________________________<br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;"><b>7b. The person's decision is affected by psychosis</b></span><br />
(Sample questions: Can you help me understand why you've decided to<br />
accept/refuse treatment? Do you think anyone is trying to hurt/harm<br />
you? Do you trust your doctor/nurse? )<br />
<b><span style="font-family: 'Trebuchet MS', sans-serif;">YES NO UNSURE</span></b> <br />
<b><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></b><br />
Observations: _____________________________________________<br />
_________________________________________________________<br />
<br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;"><b>Overall Impression </b></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><b><br />
</b></span><br />
<b><span style="font-family: Arial, Helvetica, sans-serif;">Definitely capable Probably capable Probably incapable Definitely incapable </span></b><br />
<b><span style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></b><br />
<b><span style="font-family: Arial, Helvetica, sans-serif;">Comments</span></b>: <br />
(for example: need for psychiatric assessment, further disclosure and discussion with patient<br />
or consultation with family)<br />
<br />
The initial ACE assessment is the first step in the capacity assessment process. If the ACE is definitely or probably incapable, considerable treatable or reversible causes of incapacity. Repeat the capacity assessment once these factors have been addressed. If the ACE result is probably incapable or probably<br />
capable, then take further steps to clarify the situation. For example, if you are unsure about the person’s ability to understand the proposed treatment, then a further interview which specifically focuses on this area would be helpful. Similarly, consultation with family, cultural and religious figure and/or psychiatrist,<br />
may clarify some areas of uncertainty.<br />
<br />
<b>Never base a finding of incapacity solely on your interpretation of domain 7a and 7b</b>. Even if you are sure that the decision is based on a delusion or depression, we suggest that you always get an independent<br />
assessment.<br />
<br />
Time taken to administer ACE: ______ minutes<br />
Date: ______________<br />
Assessor: _______________________________<br />
<br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><b>COMMENT</b>: You will notice that the form records its conclusion in a "fuzzy" way--"probably" vs. "definitely" capable or incapable. This is as good as it gets. If you need to seek more clarity, you seek more input (additional evaluations using the same instrument from other people who know the patient well or other professionals with special expertise in these kinds of assessments. <span style="color: #0b5394;"><b>Just remember that no expert is qualified, on his own, to make a determination that a patient is not competent to make a medical decision</b></span>. In the end, only a court can do this if the patient has not previously appointed a "health care proxy" to make these decisions when s/he should become no longer able.</span><br />
<br />
<br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><b>References</b>:</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">1. Sessums LL, Zembrzuska H, Jacksoni JL. Does this patient have medical decision-making capacity? JAMA 2011; Jul 27; 306(4): 420-7.</span>Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com1tag:blogger.com,1999:blog-340176576888120508.post-12779379544228983782012-02-17T14:37:00.000-08:002012-02-17T14:37:27.465-08:00Reliable Quick Answers to Medical Questions on the Web<div style="text-align: center;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b>A VIEW FROM THE OFFICE</b></span></div><br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_NgUKHA15B3ARJC-YfwhbtXngqtVbSP62F3SBHCpam_5N_Lt8ME1XSSPLj8d45thDhvqzbNucltY5nChFLEsa3XTTQ2KCn6PWIsKrt12m8ILA3OLssLUAdhAOaasaNOz8Udm1XtjPB68/s1600/Portola+downtown.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_NgUKHA15B3ARJC-YfwhbtXngqtVbSP62F3SBHCpam_5N_Lt8ME1XSSPLj8d45thDhvqzbNucltY5nChFLEsa3XTTQ2KCn6PWIsKrt12m8ILA3OLssLUAdhAOaasaNOz8Udm1XtjPB68/s320/Portola+downtown.jpg" width="320" /></a></div><br />
<div style="text-align: center;"><b><span style="font-family: 'Trebuchet MS', sans-serif;">RELIABLE QUICK ANSWERS TO MEDICAL QUESTIONS ON THE WEB:</span></b></div><div style="text-align: center;"><b><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></b></div><div style="text-align: center;"><b><span style="font-family: 'Trebuchet MS', sans-serif;">WELCOME TO <i><span style="color: red;">HEALTHTAP</span></i>!</span></b></div><div style="text-align: center;"><b><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></b></div><div style="text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b> </b>Two weeks ago I read in the Sunday New York Times an <a href="http://www.nytimes.com/2012/02/05/business/on-healthtap-advice-for-you-and-points-for-doctors.html?_r=1&scp=1&sq=healthtap&st=cse">article</a> about a web-based consumer information service called "<b>HealthTap</b>." It invites both consumers and physicians to join. Consumers ask the questions. Volunteer physicians provide the answer. </span><span style="background-color: white; font-family: 'Trebuchet MS', sans-serif; line-height: 1.467em;">HealthTap started its Web site last May. It has signed up more than 9,000 physicians and is adding 100 a day. The site does not carry advertising. "</span><span style="background-color: white; font-family: 'Trebuchet MS', sans-serif; line-height: 1.467em;">Users can follow particular doctors and topics of interest; new answers related to these are displayed in an “activity feed” shown when users log on to the site. </span><span style="background-color: white; line-height: 22px;"><span style="font-family: 'Trebuchet MS', sans-serif;">The site offers a peer-based reputation system of its own devising. Next to each answer, users see the number of doctors who agree; with a click, they can see who the approving doctors are, as well as something that HealthTap calls a “reputation level,” which is built by accumulating HealthTap awards, “Agrees” from fellow physicians and other measurable activities at the site." </span></span></div><div style="text-align: left;"><span style="background-color: white; line-height: 22px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></span></div><div style="text-align: left;"><span style="background-color: white; line-height: 22px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Here is a screenshot from the patient side of the <a href="http://www.healthtap.com/">website</a>:</span></span></div><div style="text-align: left;"><span style="background-color: white; line-height: 22px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJtABiBwmCPlN4W11mLr1fnaO3WHUtshxXq90EWK1q0xWdKNZILP4EaKOGJ1O6fuS_nqQGrJn4Aal_dKCt7NRPp85GBvxA59l8zfDY5HIhHW3uJE0upPrWNMkHa_4SyeRdP3ujmIsjgqI/s1600/HealthTap2.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="498" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJtABiBwmCPlN4W11mLr1fnaO3WHUtshxXq90EWK1q0xWdKNZILP4EaKOGJ1O6fuS_nqQGrJn4Aal_dKCt7NRPp85GBvxA59l8zfDY5HIhHW3uJE0upPrWNMkHa_4SyeRdP3ujmIsjgqI/s640/HealthTap2.JPG" width="640" /></a></div><div style="text-align: left;"><span style="background-color: white; line-height: 22px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
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</span></span></div><div style="text-align: left;"><span style="background-color: white; line-height: 22px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Here is a screenshot from my physician side of HealthTap.</span></span></div><div style="text-align: left;"><span style="background-color: white; line-height: 22px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh3lXeOFmWSCsDhc1fNWqEhWTsEgl9QNdP3SKiSYpMnKXMtb_pRfiGPDzlvXYog68NI3yZT9uc5P0FfVq6A53-GRlI44_4MtbVG4NZY0rhn9YiGNyzQGwhibb1C_qpjLlyUnZseNHru8CY/s1600/HealthTap1.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="498" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh3lXeOFmWSCsDhc1fNWqEhWTsEgl9QNdP3SKiSYpMnKXMtb_pRfiGPDzlvXYog68NI3yZT9uc5P0FfVq6A53-GRlI44_4MtbVG4NZY0rhn9YiGNyzQGwhibb1C_qpjLlyUnZseNHru8CY/s640/HealthTap1.JPG" width="640" /></a></div><div style="text-align: left;"><span style="background-color: white; line-height: 22px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
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</span></span></div><div class="separator" style="clear: both; text-align: center;"></div> <span style="font-family: 'Trebuchet MS', sans-serif;"> Probably the strongest feature about this site for consumers is the ability to "follow" the opinions of certain physicians who give precise, clear, practical answer. [Some of the answers are indeed too brief to be helpful.] You will be notified of new responses for the physicians that you follow. [You are certainly welcome to follow me.] </span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"> For the physicians it is an excellent opportunity to reach out to patients outside of the office and to do good for the community (in fact, a very big community--the whole internet!). It can also sharpen physician skills in communication. Trying to be helpful, succinct, and clear in only 400 characters [the limit for each answer] is a good mind-sharpening challenge. I find it an excellent way to both learn something and be useful in the few minutes between patients in the office. It is always informative to see the kinds of things that patients are concerned about but may not bring to the office. Some of the questions are distinctly challenging and send me to do online research so that we can both be educated at the same time. In my opinion, any way that a doctor can make more contact with the community is a good thing. </span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"> <b>HealthTap </b>offers a very sociable and time-efficient way of getting in touch with a treasure trove of physicians. Try it!</span><br />
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<span style="font-family: 'Trebuchet MS', sans-serif;"><b>A NOTE TO MY FRIENDS IN PLUMAS COUNTY</b>: I will be returning to do a <b><span style="color: blue;">Saturday morning clinic on March 3rd at the Portola Clinic</span></b>. The plan is for me to come back for a clinic session on the first Saturday of each month. I look forward to seeing you there.</span><br />
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<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_wRxPK-pYyNSKfzWw2Qyqg-x62QwIDRGfEFfI3KDzcEOmaRE-2FCxsMhvpnWHT_7unkMo_x3slFUl7SnhkpXX45fSPPtdJXCAlv4FCe8JSYkeSAypIu3c1DeAj5LkfXBcFLNmvvNyMYM/s1600/CPK+professional+photo.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_wRxPK-pYyNSKfzWw2Qyqg-x62QwIDRGfEFfI3KDzcEOmaRE-2FCxsMhvpnWHT_7unkMo_x3slFUl7SnhkpXX45fSPPtdJXCAlv4FCe8JSYkeSAypIu3c1DeAj5LkfXBcFLNmvvNyMYM/s320/CPK+professional+photo.jpg" width="213" /></a></div><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
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<div style="text-align: center;"><span style="font-family: 'Trebuchet MS', sans-serif;">Dr. Colin Kopes-Kerr, MD</span></div><div class="separator" style="clear: both; text-align: center;"></div><div style="text-align: left;"><span style="background-color: white; line-height: 22px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></span></div>Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com1tag:blogger.com,1999:blog-340176576888120508.post-35362388706734284772012-02-09T14:27:00.000-08:002012-02-09T14:27:49.319-08:00ARE THE TESTS YOU ARE GETTING WORTHWHILE?<div style="text-align: center;"><span style="font-family: "Trebuchet MS", sans-serif;"><strong>A VIEW FROM THE OFFICE</strong></span></div><div style="text-align: center;"><br />
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</div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpVUPLAJAFAYHiq6900qe07eOGlAHFw5TdS_eFA-PEkIGBL9m_yDNHElrgzy7q2fIOGwe9FucWJiPBYEvuEEZBMmTenCIU2Hv_dZ3LBNQ5R9u5r2isi-oEjK6JO2MA4Z9V010VBtzNjJ4/s1600/Viewfromoffice2.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" sda="true" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpVUPLAJAFAYHiq6900qe07eOGlAHFw5TdS_eFA-PEkIGBL9m_yDNHElrgzy7q2fIOGwe9FucWJiPBYEvuEEZBMmTenCIU2Hv_dZ3LBNQ5R9u5r2isi-oEjK6JO2MA4Z9V010VBtzNjJ4/s320/Viewfromoffice2.JPG" width="320" /></a></div><div style="text-align: center;"><br />
</div><div style="text-align: center;"><strong><span style="font-family: Trebuchet MS;">ARE THE TESTS YOU ARE GETTING WORTHWHILE?</span></strong></div><div style="text-align: center;"><br />
</div><div style="text-align: left;"> <span style="font-family: "Trebuchet MS", sans-serif;">An important new article in the <strong><em>Annals of Internal Medicine</em></strong> urges physicians (and ultimately their patients) to limit a lot of common testing based on the value to the patient (Will the test actually improve the patient's outcome?) and the cost to the system, which in the end we all pay.</span></div><div style="text-align: left;"> <span style="font-family: "Trebuchet MS", sans-serif;">They have selected 34 tests as appropriate targets for reduced use. Here I will comment on the tests that I have seen most often used in Plumas County with little or no benefit to either the physician or the patient.</span></div><div style="text-align: left;"><span style="font-family: Trebuchet MS;"> </span></div><div style="text-align: left;"><span style="font-family: Trebuchet MS;">1. <strong><u>Bone Mineral Density Testing</u></strong>: The national guideline from the United States Preventive Services Task Force does not call for routine DEXA scanning of average risk women until age 65. As I have explained in a recent post here, new evidence shows that for average risk women with normal DEXA scans at age 65, they do not need another one for 15 years! I have seen many women who have been coming in for one every year or every other year.</span></div><div style="text-align: left;"><span style="font-family: Trebuchet MS;"> Even for women at high-risk or who have abnormal scans at baseline, there is little evidence to suggest any benefit to repeating the scans in less than 5 years.</span> </div><div style="text-align: left;"><br />
</div><div style="text-align: left;"><span style="font-family: "Trebuchet MS", sans-serif;">2. <strong><u>Lipid panel testing.</u></strong> Many people come in for a lipid panel every year or sometimes even more often. The recommendation for asymptomatic health persons is to have this done every 5 years starting at age 30. If you're not on any treatment, there is no need to repeat more often than this. Even if you are on treatment, a British Study (The British Heart Study) has shown that once you select the treatment and just continue the medication, as long as there are no side effects, you don't need to recheck the lipid panel or adjust the dose (ever). You can still get exactly the same 33% reduction of all-cause mortality and cardiac events that you do when you get all the extra tests and medication adjustments. Why go through all that extra trouble and expense?</span></div><div style="text-align: left;"><br />
</div><div style="text-align: left;"><span style="font-family: Trebuchet MS;">3. <strong><u>Pre-operative testing:</u></strong> Many surgeons, almost all, in fact, want patients to get an elaborate set of blood tests, urinalysis, chest x-rays, and ECGs before they have any kind of elective surgery. I recently had occasion to undergo an upper GI endoscopy twice. When I had it done here, the Portola hospital did not require any specific testing, but when I need to have the endoscopy repeated at Saint Mary's they routinely threw in a requirement for blood counts, chemistry panel, coagulation tests, urinalysis, chest x-ray, and ECG. This was more than a little irksome since they did not inform me of this in advance, and because I knew it was ultimately pointless. All tests were in fact normal, and I lost both time and money. This report strongly advises against all forms of routine preoperative testing for average risk adults before any general elective surgery.</span></div><div style="text-align: left;"><span style="font-family: Trebuchet MS;"> COMMENT: Of course, this is usually not a decision you make yourself. Your surgeon makes it. But you can, and should, ask why. And don't be afraid to bring them a copy of this article and the reference supplied below to encourage them to think twice about ordering unnecessary tests.</span></div><div style="text-align: left;"><br />
</div><div style="text-align: left;"><span style="font-family: Trebuchet MS;">4. <strong><u>Colon cancer screening</u></strong>: This group also takes a strong stand against any routine colon cancer screening after the age of 75. You can get it, if you really want it, but there is no evidence of systematic benefit at this age.</span></div><div style="text-align: left;"><br />
</div><div style="text-align: left;"><span style="font-family: Trebuchet MS;">5. <strong><u>Cervical cancer screening</u></strong>: There is no reason that a healthy 65 year old woman needs additional Pap smears as long as she has had regular screening up to age 65 (every 3 years) and they have all been negative over the last 10 years.</span></div><div style="text-align: left;"><br />
</div><div style="text-align: left;"><span style="font-family: Trebuchet MS;">6. <strong><u>Prostate cancer screening</u></strong>: This group takes only the position that men over age 75 should not be screening for prostate cancer with the PSA test. I encourage the more straight forward recommendation of the United States Preventive Services Task Force--that no man, at any age, should be routinely screened for prostate cancer with a PSA test.</span></div><div style="text-align: left;"><br />
</div><div style="text-align: left;"><span style="font-family: Trebuchet MS;"> Here I describe only a handful of the 34 tests covered in the report. But these are the most common ones. If we learn to use these tests correctly, we will solve a lot of the problem. A patient should: "Think not what these tests can do for the physician, but what these tests can really do for you!"</span></div><div style="text-align: left;"><br />
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</div><div style="text-align: left;"><span style="font-family: Trebuchet MS;">REFERENCE: Qaseem A et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Annals of Internal Medicine 2012; 156:147-9.</span></div><div style="text-align: left;"><br />
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</div>Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com1tag:blogger.com,1999:blog-340176576888120508.post-40265167925113384112012-01-20T16:11:00.000-08:002012-01-20T16:11:12.269-08:00Who Knows What Their Blood Pressure Is?<div style="text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>A VIEW FROM THE OFFICE</b></span></div><br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgnCaJNHSrdFCFgwtGH__IlHQe-HiXddCy4qh6I7MYZpnVqUwtZCD-KyrAi9SU4lf3rjS3R1gXRr78hyPPvRgEcyf3LTETzcNAwCl7O_pgGHy3ERGwOwBoGJRjtQBe1Z1MIUp8ul1jL9oY/s1600/Portola+office.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgnCaJNHSrdFCFgwtGH__IlHQe-HiXddCy4qh6I7MYZpnVqUwtZCD-KyrAi9SU4lf3rjS3R1gXRr78hyPPvRgEcyf3LTETzcNAwCl7O_pgGHy3ERGwOwBoGJRjtQBe1Z1MIUp8ul1jL9oY/s320/Portola+office.JPG" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>WHO KNOWS WHAT THEIR BLOOD PRESSURE IS?</b></span></div><div class="separator" style="clear: both; text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br />
</b></span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b> </b>Everyone knows that blood pressure is one of the most important variables in health. Uncontrolled blood pressure leads over many years to strokes, heart attacks, peripheral vascular disease, aneurysms, and heart failure. </span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> Most people know that the recommended level of blood pressure is to have the upper number (systolic pressure) be less than 140 mm Hg, and to have the lower number (diastolic pressure) less than 90 mm Hg. The systolic number is the level of pressure achieved in the arteries when the heart contracts, and the diastolic number is the level of pressure in the arteries when the heart relaxes in between beats. Of these two numbers the upper systolic pressure number is the more important.</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> So, what's your blood pressure? How would one know? Most people know (if they can remember it) their blood pressure from a visit to the doctor's office. But is the number you get from the doctor's office the correct number? A large number of new studies suggests that it is not. </span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> First, there is the factor of "<b>white coat hypertension</b>," which by now most of my patients seem to know about; this is when your blood pressure is transiently elevated because one may feel somewhat nervous or anxious about going to the doctor. <b>Pain </b>is another factor that will elevate the blood pressure in a doctor's office. </span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> A second factor is that in the busy flow of doctors' office practice, <b><span class="Apple-style-span" style="color: blue;">the correct technique for measurement may not be employed</span></b>. According to the experts, <b><span class="Apple-style-span" style="color: blue;">the proper way of measuring blood pressure is to check it after at least 5 minutes of quiet sitting waiting for the doctor</span></b>. In most practices, the nurse checks it as soon as or right before leading a patient into the exam room, which is not optimal. Usual practice, however, is for the doctor to re-measure any high readings after 5 minutes has passed. If the patient has been waiting for 45 minutes to an hour for the doctor, however, the blood pressure may be elevated just due to aggravation.</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> The <b><span class="Apple-style-span" style="color: blue;">expert recommendations </span></b>also call for the blood pressure to be taken <b>while the patient is sitting upright in a chair with his/her back supported and the feet flat on the floor</b>. Checking the patients' blood pressure while they are sitting on the exam table with their backs unsupported and their feet dangling in the air is not consistent with these standards, but it is, in fact, the most common way blood pressure is measured in the office. </span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> Other problems that occur in doctors' office are the use of an <b>incorrect cuff size</b> (cuffs that are too small tend to elevated the pressure readings) due to an inexperienced staff person. Also, the <b>blood pressure devices</b> themselves can get banged up, dropped, or just old and no longer give accurate readings.</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> <b><span class="Apple-style-span" style="color: blue;">For all of these reasons and some others a single blood pressure measurement in a doctor's office is simply not a reliable indicator of the true blood pressure.</span></b> </span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> A new study in the </span><b style="font-family: 'Trebuchet MS', sans-serif;"><i>Annals of Internal Medicine*</i></b><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> concludes that: "<b><span class="Apple-style-span" style="color: blue;">Physicians who want to have 80% or more certainty that they are correctly classifying patients' BP control should use the average of several measurements</span></b>. Hypertension quality metrics based on a single clinic measurement potentially misclassify a large proportion of patients." The data from this study show clearly that patients could not be classified as having BP that was in or out of control with 80% certainty on the basis of a single clinic systolic blood pressure measurement anywhere in the range from 120 mm Hg to 157 mm Hg. <b><span class="Apple-style-span" style="color: blue;">The investigators recommend obtaining an average of several measurements and feel that the optimal number of readings to average is 5 to 6.</span></b></span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> Based on several other studies it now appears that <b><span class="Apple-style-span" style="color: blue;">the optimal way to measure and manage patients' blood pressure is for the patients to monitor their blood pressure at home</span></b> with the increasingly accurate and inexpensive automatic measuring devices that are now available. This is actually better than using the numbers obtained in the doctor's office, even if the doctor does go through the trouble to average 5-6 readings. (Most don't!)</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> I advise patients not to be obsessive about it. (This tends to raise your blood pressure.) There is no point in checking it several times a day; nor is there any need really to check it more than twice a week. I tell most patients that once a week is fine. Ideal management calls for patients to bring into their doctor a list or log of at least 5-6 recent measurements so that a reliable average blood pressure may be obtained. In the near future, I expect that the makers of the blood pressure devices will computerize and memorize hundreds of measurements so that a continuous average is reported automatically. Until then we'll just have to obtain an average the old fashioned way--add up all the numbers and divide by the number of readings. The improvement that should come soon to doctors' offices is that electronic medical record system will begin to automatically calculate the average of multiple physician readings.</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> It is certainly clear to me in my practice that blood pressures vary quite erratically for many patients, and I only make my decisions on blood pressure medication adjustment based on an average blood pressure. <b><span class="Apple-style-span" style="color: blue;">I recommend that all patients who have been told that they have high blood pressure get themselves a home blood pressure measuring device (now available for less than $50). If they can bring in at least 5-6 readings from home every 4 months we will really be able to do a great job of managing hypertension</span></b>.</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">* References: </span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">(Powers BJ et al, "Measuring blood pressure for decision making and quality reporting: Where and how many measures?" 2011; 154: 781-788; editorial by Appel LJ et al., "Improving the measurement of flood pressure: Is it time for regulated standards?" 154: 836-7)</span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> </span></div>Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com2tag:blogger.com,1999:blog-340176576888120508.post-61457603612282762512012-01-19T16:36:00.000-08:002012-01-19T16:36:10.819-08:00STUDY CALLS FOR REDUCED USED OF BONE MINERAL DENSITY TESTING<div style="text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>THE VIEW FROM THE OFFICE</b></span></div><div style="text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br />
</b></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhjx_PsOfNs8mxbZFGprAUO8mgpnwafDcMWsBYOKNUOcgkwhkGVWHgPibgoU01cc33IQUzJU-7Xoyau49Fryf7O2RWgOIR9RaZ30hNuW6fVroZfeyKFuna9DJuu7j38Bg72_pT_or2KESE/s1600/Portola+View+from+the+Office.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhjx_PsOfNs8mxbZFGprAUO8mgpnwafDcMWsBYOKNUOcgkwhkGVWHgPibgoU01cc33IQUzJU-7Xoyau49Fryf7O2RWgOIR9RaZ30hNuW6fVroZfeyKFuna9DJuu7j38Bg72_pT_or2KESE/s320/Portola+View+from+the+Office.jpg" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>STUDY CALLS FOR REDUCED BONE MINERAL DENSITY TESTING FOR OSTEOPOROSIS</b></span></div><div class="separator" style="clear: both; text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br />
</b></span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b> </b>It is a long-standing problem that <span class="Apple-style-span" style="color: blue;"><b>there has been little or no hard evidence to guide the decision on how to screen for and prevent osteoporosis</b></span>. The United States Preventive Services Task Force has gone ahead and endorsed it despite the lack of evidence. The recent "Welcome to Medicare" guidelines will pay for it every 2 years. I have long been opposed to this test because it is expensive and because no one is sure how to use it. <b><span class="Apple-style-span" style="color: blue;">The vast majority of its value lies in the first screening</span></b> with a bone density test technique, and, simply stated, none of the numerous experts has any real idea of if and when to repeat the test for patients who are normal, for patients who have osteopenia, and/or for patients who have actual osteoporosis. <b><span class="Apple-style-span" style="color: blue;"> My recommendation has been for everyone simply to exercise regularly and take the recommended amount of daily calcium (1000 mg/day) and vitamin D (800 IU/day).</span></b></span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> Until now, that is. A study just published today in the <b><i>New England Journal of Medicine</i></b> (Gourlay ML et al. NEJM 2012; 366: 225-33) answered the question. They studied a group of<b> 4957 women, 67 years of age or older</b>, who had normal initial bone density or had only mild osteopenia on initial testing; these women had no history of fracture of the wrist, hip, or spine and were not taking medications like <b><i>Fosamax </i></b>for osteoporosis. <b><span class="Apple-style-span" style="color: blue;">They analyzed their bone density at 2 years, 6 years, 8 years, 10 years, and 16 years.</span></b> They divided their subjects into 3 subgroups: a group with normal bone density and a group with osteopenia (mild, moderate, and severe) and analyzed the time until progression to frank osteoporosis. </span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> <b><span class="Apple-style-span" style="color: blue;">The estimated time for women with normal bone density to progress to osteoporosis was 16.8 years</span></b>. The estimated time for women with <b>mild osteopenia</b> to progress to osteoporosis was <b>17.3 years</b>, for women with <b>moderate osteopenia, 4.7 years</b>; and for women with <b>severe osteopenia, 1.1 years</b>.</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> <b><span class="Apple-style-span" style="color: blue;"><u>The investigators conclude that the appropriate re-screening interval in which to repeat any type of bone density testing was 15 years for either normal women or women with mild osteopenia. </u></span></b>For women with moderate osteopenia, rescreening should take place in 5 years, and for women with advanced osteopenia, rescreening should take place every years.</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> This recommendation is clear and firmly evidence-based. A majority of the currently carried out rescreening with bone density tests, usually on an annual or biannual basis, should cease. <b><span class="Apple-style-span" style="color: blue;">Live a healthy lifestyle, exercise, take your calcium and vitamin D, and say your prayers--"Lord, may I live another 15 years." </span></b> Then you can get your repeat bone density test and derive some benefit from it. The rest is waste for women with normal bone density or only mild osteopenia.</span></div><div class="separator" style="clear: both; text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br />
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</b></span></div>Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com1tag:blogger.com,1999:blog-340176576888120508.post-59148152029616238382011-12-01T09:07:00.000-08:002011-12-01T09:07:17.974-08:00Why Am I Reading This?<div align="center" class="MsoNormal" style="text-align: center;"><b style="mso-bidi-font-weight: normal;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">THE VIEW FROM THE OFFICE</span></b></div><div align="center" class="MsoNormal" style="text-align: center;"><b style="mso-bidi-font-weight: normal;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></b></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhy_Y8APYqAUNVk4ZIX8xlZ4zoO5Wz5EUwPNlvzyArtHk_iDWuzZp2pqofoc6aoiABhVOQhB1FJCZT-GPgNhcn8XJUjjQxr3AAGNTqAj0_YHC9qFuD-wP-VlbJKhDgtpSpVFVMJVsE3tw/s1600/Portola+Over+the+Bridge.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhy_Y8APYqAUNVk4ZIX8xlZ4zoO5Wz5EUwPNlvzyArtHk_iDWuzZp2pqofoc6aoiABhVOQhB1FJCZT-GPgNhcn8XJUjjQxr3AAGNTqAj0_YHC9qFuD-wP-VlbJKhDgtpSpVFVMJVsE3tw/s320/Portola+Over+the+Bridge.jpg" width="320" /></span></a></div><div align="center" class="MsoNormal" style="text-align: center;"><b style="mso-bidi-font-weight: normal;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></b></div><div align="center" class="MsoNormal" style="text-align: center;"><b style="mso-bidi-font-weight: normal;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></b></div><div align="center" class="MsoNormal" style="text-align: center;"><b style="mso-bidi-font-weight: normal;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></b></div><div align="center" class="MsoNormal" style="text-align: center;"><b style="mso-bidi-font-weight: normal;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">WHY AM I READING THIS?<o:p></o:p></span></b></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span>Before we answer that question, I want to you to read and remember these 4 words. </span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal" style="text-indent: .5in;"><b style="mso-bidi-font-weight: normal;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="color: blue;">APPLE<span style="mso-tab-count: 1;"> </span></span><span class="Apple-style-span" style="color: lime;">MR. JOHNSON</span><span style="mso-tab-count: 1;"><span class="Apple-style-span" style="color: lime;"> </span> </span><span class="Apple-style-span" style="color: red;">CHARITY<span style="mso-tab-count: 2;"> </span></span><span class="Apple-style-span" style="color: purple;">TUNNEL</span><o:p></o:p></span></b></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-tab-count: 1;"> </span>Moving on. Now your second task, before I let you go is to:<span style="mso-spacerun: yes;"> </span><b>DRAW A CLOCK THAT SAYS <st1:time hour="11" minute="15">11:15 am</st1:time>.</b></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-tab-count: 1;"> </span>The question I would like to discuss in this essay is:<span style="mso-spacerun: yes;"> </span><b><span class="Apple-style-span" style="color: blue;">When is poor and declining memory significant?</span></b><span style="mso-spacerun: yes;"><b><span class="Apple-style-span" style="color: blue;"> </span></b> </span>As we each experience it, do we also need to worry about Alzheimer’s disease? Fortunately, the answer is <b><span class="Apple-style-span" style="color: blue;">mostly NOT</span></b>. But let me explain.</span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-tab-count: 1;"> </span>We’ll start with consideration of a case that was recently described in the <b><i>New England Journal of Medicine</i></b> (1):<span style="mso-spacerun: yes;"> </span>A 77-year-old woman has been noticing increasing forgetfulness over the past 6 to 12 months. Although she has always had some difficulty recalling the names of acquaintances, she is now finding it difficult to keep tract of appointments and recent telephone calls. The process has been insidious. She lives independently in the community and drives a car. She pays her own bills and maintains good hygiene and an attractive appearance.</span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-tab-count: 1;"> </span>This case is an example of what is called “mild cognitive impairment.” To put this into perspective it is worth noting that <b><span class="Apple-style-span" style="color: blue;">only 1% of all elderly patients will be fortunate enough to experience NO cognitive decline</span></b>. For the rest of us, we have to expect some. In fact, 10-20% of us who are over the age of 65 will experience this same condition—mild cognitive impairment.<span style="mso-spacerun: yes;"> </span>The good news is that, of this 10-20%, only 10% will go on to develop Alzheimer’s disease.<span style="mso-spacerun: yes;"> </span>As we get even older, among persons aged 70-89, 11%<span style="mso-spacerun: yes;"> </span>will experience mild cognitive impairment; 4.9% will develop Alzheimer’s disease.</span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-tab-count: 1;"> </span>A more recent <b><i>New England Journal of Medicine</i></b> published another case, one that I feel can lift some our anxieties if we are among the unfortunate few who develop Alzheimer’s disease.(2) Here is Michael Donohue’s story. </span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-tab-count: 1;"> </span><strong><span style="font-weight: normal; mso-bidi-font-weight: bold;">"</span></strong><i>At the age of 69, a year after retiring from his practice as a <st1:city><st1:place>Minneapolis</st1:place></st1:city> trial lawyer, Mike Donohue noticed his driving skills deteriorating. His wife persuaded him to undergo a simulated driving examination. 'I flunked it miserably,' he recalls. Donohue consulted his physician, underwent tests, and learned that he had early Alzheimer's disease. His doctor told him, 'Take this medication, call me in a year, and call the Alzheimer's Association.'</i>"<o:p></o:p></span></div><div style="margin-bottom: .0001pt; margin: 0in;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> Try to imagine for a moment your reaction to both this information and this manner of care.<o:p></o:p></span></div><div style="margin-bottom: .0001pt; margin: 0in;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> Fortunately, this patient did not resign himself to such implied pessimism. He called the Alzheimer's Association's local office. He volunteered there, where he met other people with early-stage disease, helped to launch some programs for them, and<span class="apple-converted-space"> </span>now,<span class="apple-converted-space"><span style="mso-bidi-font-weight: bold;"> </span></span><strong><span style="font-weight: normal; mso-bidi-font-weight: bold;">5 years later, serves on an advisory committee about services for people with newly diagnosed Alzheimer's disease and their family. Recently, he and several friends with the condition entered a new program where they’ll serve as mentors for others with a new Alzheimer's diagnosis</span></strong>.<o:p></o:p></span></div><div style="margin-bottom: .0001pt; margin: 0in;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> '<i>There's a great loneliness out there</i>, Donohue says. '<i>It comes from the stereotype that we’re all drooling in a corner,' even though most people living with the diseases are in community settings rather than nursing homes. '</i><strong><span style="font-weight: normal; mso-bidi-font-weight: bold;"><i>My cognition remains good, and until recently my memory remained reasonably good. These friendships are so important to me</i>.'<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></strong></span></div><div style="margin-bottom: .0001pt; margin: 0in; text-indent: .5in;"><strong><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="font-weight: normal;">One of</span><span style="font-weight: normal;"> </span><span class="Apple-style-span" style="font-weight: normal;">the pieces of major good news amid the spreading epidemic of Alzheimer’s disease is that we are having larger numbers of people survive and function well with a meaningful social life. </span><span class="Apple-style-span" style="color: blue;">The modern Alzheimer’s disease is <u>not</u> the end of the road</span><span class="Apple-style-span" style="font-weight: normal;">. This is a more important fact than that research so far has failed to identify any medications that truly make a big difference for persons with Alzheimer’s. <o:p></o:p></span></span></strong></div><div style="margin-bottom: .0001pt; margin: 0in; text-indent: .5in;"><br />
</div><div style="margin-bottom: .0001pt; margin: 0in; text-indent: .5in;"><strong><span style="font-weight: normal; mso-bidi-font-weight: bold;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Let’s return to our original point. There is mild cognitive impairment and there is Alzheimer’s disease. Where in this spectrum , for the 99% of us not destined to have no cognitive impairment at all, do we fit in with our ordinary failings of memory. What do you forget?<span style="mso-spacerun: yes;"> </span>Here are some typical examples. <o:p></o:p></span></span></strong></div><div style="margin-bottom: .0001pt; margin: 0in; text-indent: .5in;"><strong><span style="font-weight: normal; mso-bidi-font-weight: bold;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></span></strong></div><div style="margin-left: .5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -.25in;"><!--[if !supportLists]--><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-list: Ignore;">•<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->Difficulty with word finding (we all do this)<o:p></o:p></span></div><div style="margin-left: .5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -.25in;"><!--[if !supportLists]--><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-list: Ignore;">•<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->Difficulty with recalling names (most of us do this at least some of the time)<o:p></o:p></span></div><div style="margin-left: .5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -.25in;"><!--[if !supportLists]--><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-list: Ignore;">•<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->Forgetting why you went into a room (we all do this)<o:p></o:p></span></div><div style="margin-left: .5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -.25in;"><!--[if !supportLists]--><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-list: Ignore;">•<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->Forgetting where you put something (we all do this)<o:p></o:p></span></div><div style="margin-left: .5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -.25in;"><!--[if !supportLists]--><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-list: Ignore;">•<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->Forgetting appointments (this is a little bit more severe forgetfulness)<o:p></o:p></span></div><div style="margin-left: .5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -.25in;"><!--[if !supportLists]--><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-list: Ignore;">•<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->Forgetting telephone calls (this is a little bit more severe forgetfulness)<o:p></o:p></span></div><div style="margin-left: .5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -.25in;"><!--[if !supportLists]--><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-list: Ignore;">•<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->Forgetting recent events that you participated in (this is quite severe forgetfulness)</span></div><div style="margin-left: .5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -.25in;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">So assume you or I are doing at least the first four items a lot. What does it mean? Are they going to take us away in the morning? Fortunately not. The lesson here is that this is the new normal. When 99% of the population repeatedly encounter this kind of experience, on a statistical basis, it is clearly normal behavior.</span><br />
<div style="text-indent: .5in;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">So, when should I worry?</span></div><div style="text-indent: .5in;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">There are some simple cues.</span></div><div style="text-indent: .5in;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">First of all, <b><span class="Apple-style-span" style="color: blue;">if you’re aware enough to be concerned about how memory may be interfering with your overall function, you probably don’t have Alzheimer’s</span></b>. It is characteristic of the global cognitive defects in Alzheimer’s that the patient is not explicitly aware of the number and nature of the defects and the degree of impairment. Patient’s with Alzheimer’s don’t go on their own to the doctor to ask about their memory. Friends or family members bring them and the friends or family members ask the questions about memory and provide the behavioral details. On the other hand, <b><span class="Apple-style-span" style="color: blue;">patients with mild cognitive impairment frequently go to the doctor to express their concern about their slow decline from their peak mental performance. The question they ask the doctor is, “Is this anything to worry about, Doc?”</span></b><span style="mso-spacerun: yes;"><b><span class="Apple-style-span" style="color: blue;"> </span></b> </span>If the patient is asking this question, then the doctor can generally be very comfortable in say, “<b><span class="Apple-style-span" style="color: blue;">Nope. This is just part of the new you (and me, I might add)</span></b>.”</span></div><div style="text-indent: .5in;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Remember the little tasks I asked you to do right at the beginning of this essay. This would be a good time to take a look at the clock you drew. If you drew a clock with a full closed circle, 2 hands, one longer than the other, centered in the middle of the clock, 12 digits, each at least in the appropriate quadrant, and had the hands at the right time, you’re good. You don’t have Alzheimer’s disease.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span></span><!--[endif]--></div><span style="mso-spacerun: yes;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> </span></span><br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgzi3JrkzshBifC611ICxzWlAv70jwZqROdAOkRWkITs7Xxu2bj0Lx54m5X2vbuvuaxmUclNkzBK1gMgU4G3MOruWLqcHbfIcrPlWuh954oNaoIQgLkB0S4x1bsmq46opTymLREn8M45rM/s1600/Clock+drawing+test+normal+web+large.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgzi3JrkzshBifC611ICxzWlAv70jwZqROdAOkRWkITs7Xxu2bj0Lx54m5X2vbuvuaxmUclNkzBK1gMgU4G3MOruWLqcHbfIcrPlWuh954oNaoIQgLkB0S4x1bsmq46opTymLREn8M45rM/s320/Clock+drawing+test+normal+web+large.jpg" width="320" /></a></div><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Figures 1 and 2: This clock passes the test. All the other clocks below do not.</span><br />
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<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEif3Znf-kiMBUyvUovkQJTbx3EtLwMDI_mx-rBq120QgfWzcpZI2wOl-iAN6X1NRNezwwLPV2Gj-d33GLHnKTsPSsruJpO4HW-wZqEanXQDK2J-ZSc7oJol2MTx11g1-UvbKLouVsFWyTc/s1600/Clock+drawing+test+abnormals+web+large.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEif3Znf-kiMBUyvUovkQJTbx3EtLwMDI_mx-rBq120QgfWzcpZI2wOl-iAN6X1NRNezwwLPV2Gj-d33GLHnKTsPSsruJpO4HW-wZqEanXQDK2J-ZSc7oJol2MTx11g1-UvbKLouVsFWyTc/s1600/Clock+drawing+test+abnormals+web+large.JPG" /></a></div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
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<div style="text-indent: .5in;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Why can we say this? It is because Alzheimer’s disease affects more than simple memory. One of its prominent effects is impairment or destruction of our sense of space, which is what, is tested with the clock test. The inability to pass this test is one of the earliest signs of Alzheimer’s disease. It’s one you can use yourself for someone about whom you may be concerned. (Just ask them to draw a clock that shows <st1:time hour="11" minute="15">11:15 a.m.</st1:time>) Generally, as long as all the little cognitive defects are only in the area of memory, and not in the realm of visuospatial sense, motor skills, or coordination, that the worst we are talking about is mild cognitive impairment, which all your friends have too. So don’t feel so bad.</span></div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Another way to recognize whether it is more than just mild cognitive impairment is to think about how you function in your life. <b><span class="Apple-style-span" style="color: blue;">Can you adequately do all your routine daily tasks?</span></b> People with mild cognitive impairment can, no matter how irritated they may be at forgetting some of the details. People with Alzheimer’s can’t. They just can’t. </span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Here are some of the tasks that patients with Alzheimer’s often cannot do:</span><br />
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<div style="margin-left: .75in; mso-list: l1 level1 lfo2; tab-stops: list .75in; text-indent: -.25in;"><!--[if !supportLists]--><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->Write checks, pay bills, keep financial records</span></div><div style="margin-left: .75in; mso-list: l1 level1 lfo2; tab-stops: list .75in; text-indent: -.25in;"><!--[if !supportLists]--><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->Put together tax records, business records, or personal papers</span></div><div style="margin-left: .75in; mso-list: l1 level1 lfo2; tab-stops: list .75in; text-indent: -.25in;"><!--[if !supportLists]--><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->Shop alone for clothes, household necessities, or groceries</span></div><div style="margin-left: .75in; mso-list: l1 level1 lfo2; tab-stops: list .75in; text-indent: -.25in;"><!--[if !supportLists]--><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->Play a game of skill or work on a hobby</span></div><div style="margin-left: .75in; mso-list: l1 level1 lfo2; tab-stops: list .75in; text-indent: -.25in;"><!--[if !supportLists]--><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->Heat water, make a cup of coffee, or remember to turn off the stove</span></div><div style="margin-left: .75in; mso-list: l1 level1 lfo2; tab-stops: list .75in; text-indent: -.25in;"><!--[if !supportLists]--><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->Keep track of current events</span></div><div style="margin-left: .75in; mso-list: l1 level1 lfo2; tab-stops: list .75in; text-indent: -.25in;"><!--[if !supportLists]--><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->Pay attention to a TV program, book, or magazine and report the story</span></div><div style="margin-left: .75in; mso-list: l1 level1 lfo2; tab-stops: list .75in; text-indent: -.25in;"><!--[if !supportLists]--><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-list: Ignore;">8.<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->Remember appointments, special family events, holidays, or medications</span></div><div style="margin-left: .75in; mso-list: l1 level1 lfo2; tab-stops: list .75in; text-indent: -.25in;"><!--[if !supportLists]--><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-list: Ignore;">9.<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->Drive out of the neighborhood safely in a car, or plan how to use a bus system.</span></div><div style="margin-left: .75in; mso-list: l1 level1 lfo2; tab-stops: list .75in; text-indent: -.25in;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-indent: .25in;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">So, if you’re currently doing all these functions OK, you have nothing to worry about at this time. You still, however, will forget things.</span></div><div style="text-indent: .25in;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">OK. So now you’re at the point of accepting that you have some memory lapses and probably have mild cognitive impairment. <b>What do you do about it?</b> <b><span class="Apple-style-span" style="color: blue;">First, don’t worry so much about it. Second, become proactive.</span></b> There’s a lot you can do.</span></div><div style="text-indent: .25in;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The first proactive step is to <span class="Apple-style-span" style="color: blue;"><b>get active</b></span>. Exercise prevents cognitive impairment and a host of other problems too. "<i>Recent epidemiologic, cohort, and clinical-trial data support a role for physical activity in maintaining cognitive health. This was studied in more than <span style="mso-bidi-font-weight: bold;">2800 female health professionals over the age of 65 with at least 3 vascular risk factors<b> </b></span>(e.g., diabetes mellitus, hypertension, hyperlipidemia, body-mass index > 30, family history of premature myocardial infarction). Participants reported mean one-year physical activity levels a mean of 3.5 years before an initial global cognitive evaluation. <span style="mso-bidi-font-weight: bold;">Women in the two highest quintiles of physical activity level--equivalent to brisk walking > 30 minutes daily--had significantly slower rates of cognitive decline than those in the lowest quintile. </span>When the data were compared to an analysis of age-associated cognitive decline, <span style="mso-bidi-font-weight: bold;">participants in the 2 highest quintiles of physical activity were cognitively 5 to 7 years 'younger' than those in the lowest quintile</span>. A secondary analysis specific to walking showed a possible threshold effect, <span style="mso-bidi-font-weight: bold;">with at least 30 minutes of brisk daily walking required for significant cognitive benefit</span>." </i>(3)</span></div><div style="text-indent: .25in;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-tab-count: 1;"> </span>My recommendation, following the <st1:country-region><st1:place>US</st1:place></st1:country-region> national exercise recommendation, is to engage in <b><span class="Apple-style-span" style="color: blue;">at least 150 minutes of exercise, at least brisk walking, each week</span></b>—broken up in any way you want to do it.</span></div><div style="text-indent: .25in;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Second, <b><span class="Apple-style-span" style="color: blue;">do mental exercises regularly</span></b>. In a recent comprehensive review of all studies of various kinds of mental exercises “<i>The data showed statistically significant <span style="mso-bidi-font-weight: bold;">improvements at the end of training on 44% of <u>objective</u> measures of memory</span> and statistically significant improvements after treatment were obtained on </i><span style="mso-bidi-font-weight: bold;"><i>49% of subjective measures of memory, quality of life, or mood</i>.</span>” (4)<o:p></o:p></span></div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">And, of course, I am going to recommend <b><span class="Apple-style-span" style="color: blue;">eating healthy—5 servings of fruits and vegetables a day, lots of grains, small (4 oz) portions of red meat, and a regular multiple vitamin with calcium and vitamin D</span></b>.<span style="mso-spacerun: yes;"> </span>All this is with a view to <b><span class="Apple-style-span" style="color: blue;">keep your <st1:stockticker>BMI</st1:stockticker> (body mass index) below 30.</span></b></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-tab-count: 1;"> </span>Of course, you’re <b><span class="Apple-style-span" style="color: blue;">not going to smoke</span></b> because smoking leads to narrowed blood vessels, and, if you care about your memory, you want your precious little brain cells to get every ounce of circulation they can.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="mso-tab-count: 1;"> </span>Finally, carry out a plan for some time spent <b><span class="Apple-style-span" style="color: blue;">relaxing every day</span></b>. Relaxing can be going for a quiet walk, time with a pet, reading, dancing, reading the Bible, watching a good movie<span style="mso-spacerun: yes;"> </span>(no sex, no violence, no commercials), of doing something creative—gardening, painting, writing, interior design, refurbishing an old car, whatever gets you in your groove. Memory cells like it when you relax and turn off all the other chatter and clutter of your daily life.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Actually, this advice is rather simple. You’ve heard it before. It’s no more than the <b><span class="Apple-style-span" style="color: lime;">Formula for Health</span></b>. Give it a try! </span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
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<div class="MsoNormal" style="text-indent: .5in;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">By the way, if you can still remember <span style="mso-spacerun: yes;"> </span><b style="mso-bidi-font-weight: normal;"><span class="Apple-style-span" style="color: blue;">APPLE </span><span class="Apple-style-span" style="color: lime;"> MR. JOHNSON</span><span style="mso-tab-count: 1;"> </span><span class="Apple-style-span" style="color: red;">CHARITY</span><o:p></o:p></b></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b style="mso-bidi-font-weight: normal;"><span class="Apple-style-span" style="color: purple;">TUNNEL</span></b>, you’re doing pretty good.</span></div><div style="margin-bottom: .0001pt; margin: 0in; text-indent: .5in;"><br />
</div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Colin Kopes-Kerr, MD</span><br />
<st1:date day="29" ls="trans" month="9" year="2011"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">December 1, 2011</span></st1:date><br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEguG5XL0TZh961B0TFMRjZnBH3ctQXmMS-Ov3na_5bM8cm7hiwvvf-gYj44zoTq0D7f7x90Bvmjr9zhwmOZ_OmoHbWMCvlcWsRVRakL8ELqWp7_iM0wl6y-jheLrvm3J06su0PR2vFxn3s/s1600/Formula+w+data+%2526+check+marks+EPHC.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEguG5XL0TZh961B0TFMRjZnBH3ctQXmMS-Ov3na_5bM8cm7hiwvvf-gYj44zoTq0D7f7x90Bvmjr9zhwmOZ_OmoHbWMCvlcWsRVRakL8ELqWp7_iM0wl6y-jheLrvm3J06su0PR2vFxn3s/s640/Formula+w+data+%2526+check+marks+EPHC.jpg" width="484" /></a></div><div align="center" style="text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
<!--[endif]--></span></div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><u>References</u>: </span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">1. Petersen RC. Mild Cognitive Impairment. <st1:place>New England</st1:place> Journal of Medicine 2011; 364: 2227-34.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">2. Okie S. Confronting Alzheimer’s Disease. <st1:place>New England</st1:place> Journal of Medicine 2011; 365: 12: 1069-72.</span><br />
<div class="MsoNormal" style="line-height: 17.4pt;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">3. Middleton LE et al. Activity energy expenditure and incident cognitive impairment in older adults. Archives of Internal Medicine 2011; 171(14): 1251-7.</span></div><span style="font-size: 12pt;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">4. Jean L et al. Cognitive intervention programs for individuals with mild cognitive impairment: Systematic review of the literature. American Journal of Geriatric Psychi</span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">atry 2010; 1</span>Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com1tag:blogger.com,1999:blog-340176576888120508.post-80913866847471292642011-11-10T10:10:00.000-08:002011-11-10T14:19:56.326-08:00<div style="text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>SOME DRUG INFORMATION</b></span></div><div style="text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br />
</b></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSny7pzoUddD11Kyb9rfX5mSJwfUoF3YqB3j-FqOhLx0KhxbnVOZYCVRdKSsahmnevFqQfk-PLiuOZrlReNsOxW8-n8iduGU4qPA0LI6CT5030PsiyDN8giiFYeJhk_WXJR4cxj5Wc_Tk/s1600/Portola+View+from+the+Office.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSny7pzoUddD11Kyb9rfX5mSJwfUoF3YqB3j-FqOhLx0KhxbnVOZYCVRdKSsahmnevFqQfk-PLiuOZrlReNsOxW8-n8iduGU4qPA0LI6CT5030PsiyDN8giiFYeJhk_WXJR4cxj5Wc_Tk/s320/Portola+View+from+the+Office.jpg" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>The View From the Office</b></span></div><div class="separator" style="clear: both; text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br />
</b></span></div><div class="separator" style="clear: both; text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>SOME NEW DRUG INFORMATION</b></span></div><div class="separator" style="clear: both; text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>Cholesterol Medications</b>: The cholesterol medication with the greatest name recognition, <b><i>Lipitor</i></b>, goes generic at the end of this month; <span class="Apple-style-span" style="color: blue;"><b>it will then be the preferred generic statin medication</b></span>. Many people should consider changing their cholesterol medication in order to take advance of this more potent, and now finally, less expensive drug for cholesterol.</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>Drugs for Osteoporosis</b>: (<i><b>Fosamax</b></i>, etc.): The new consensus is that patients should <u><b>not</b></u> just remain on these medications forever, once they start. Most experts are calling for stopping the medication after 5 years, unless there is a recent osteoporotic fracture. Some experts recommend stopping after 3 to 5 years and then rechecking a bone density test in 2 to 3 years to see if there is relapse. <b><span class="Apple-style-span" style="color: red;">T</span></b><span class="Apple-style-span" style="color: red;"><b>he problem with taking these medications too long are that you can get a condition called "osteonecrosis of the jaw" (no fun) and/or atypical femoral fractures.</b></span> All of these drugs are different forms of a chemical called BISPHOSPHONATES, and these stay in the bone for years even after stopping the medication. </span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> <i><u>Prescriber's Letter</u></i> recommends that everyone take 1200 mg of elemental calcium daily and 800 to 2000 IU of vitamin D3.</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><i>SAW PALMETTO</i> is Losing Its Fans</b>: <i><u>Prescriber's Letter</u></i> predicts that saw palmetto will fall out of favor for treating symptoms of enlarged prostate (BPH). Two new NIH-sponsored trials now suggest that <span class="Apple-style-span" style="color: blue;"><b>saw palmetto is <u>NOT</u> better than placebo</b></span> for BPH symptoms...even at high doses. "In fact, our <b><i><u>Natural Medicines Comprehensive Database</u></i></b> is downgrading its rating of saw palmetto to "<span class="Apple-style-span" style="color: red;"><b>Possibly Ineffective</b></span>."</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> This expert group recommends telling men not to rely on saw palmetto for BPH. Explain that benefits are modest at best. There is no need to be overly concerned, however, if men want to try it, there's no evidence of serious adverse effects.</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>PROBLEMS with MAGNESIUM and PPI medications (e.g., Prilosec, Nexium, Protonix, Prevacid, Aciphex, etc.):</b> Medications like Prilosec (omeprazole) may lower magnesium levels. These experts recommend <span class="Apple-style-span" style="color: blue;"><b>checking a blood test</b></span> for magnesium in patients who have been on PPIs for a long time. Other drugs that can lower magnesium are diuretics for hypertension or heart failure, and some of the cancer drugs like cisplatin. Also, if you are having a problem with either calcium or potassium, consider doing blood tests for all 3 -- calcium, potassium, and magnesium. It will be difficult to correct low calcium or potassium if the magnesium remains low.</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> If your magnesium is low and you need a <span class="Apple-style-span" style="color: blue;"><b>supplement</b></span>, consider the one that is <span class="Apple-style-span" style="color: blue;"><b>best absorbed--magnesium lactate (Mag-Tab SR), magnesium chloride (Slow-Mag), or magnesium aspartate (Maginex)</b></span>. Magnesium oxide is easier to get (Mag-Ox) and has more elemental magnesium than the others, but it is not well absorbed. Better absorption means less diarrhea. You can use IV magnesium sulfate for severe deficiencies. Ultimately, if the magnesium does improve in a patient on a PPI, stop the PPI, and substitute an anti-histamine acid drug like Pepcid.</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> <i><u>Prescriber's Letter</u></i> recommends avoiding magnesium supplements in patients with renal insufficiency, which is pretty common in our neck of the woods.</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>A Guideline to Reduce Your Risk of Ulcer from ANTI-INFLAMMATORY DRUGS:</b></span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br />
</b></span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b> LOW GI RISK MODERATE GI RISK HIGH GI RISK</b></span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br />
</b></span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>LOW </b>ibuprofen or 1.Celebrex alone 1.avoid NSAIDs</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>CARDIAC </b>Alleve 2.ibuprofen, etc, + PPI </span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">2.Celebrex + PPI</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>RISK </b></span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">or Cytotec</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> 3. NSAID + double-dose </span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> Pepcid or </span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Zantac (etc.)</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br />
</b></span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>HIGH </b> Naproxen 1. Naproxen + PPI or Cytotec Avoid all NSAIDS</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>CARDIAC </b>2. Naproxen + double-dose </span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>RISK </b>Pepcid </span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">or Zantac, etc.</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br />
</b></span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>Note: NSAIDs</b> include all anti-inflammatory drugs except aspirin--e.g., ibuprofen, Advil, Nuprin, Alleve, naproxen, Mobic, Relafen, Clinoril/sulindac, etc.</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>THYROID MEDICATION: You May Not Need As Much</b>: The fact is that <span class="Apple-style-span" style="color: blue;"><b>younger people, if their thyroid gland is not producing enough hormone, need more hormone replacement (levothyroxine) than older people. </b></span>Younger adults need about 1.7 mcg/kg/day of levolthyroxine but some seniors need only 0.5 mcg/kg/day. I have been seeing several older patients recently who have been on the same dose of levothyroxine for over 10 years, but all of a sudden on a routine thyroid test (TSH), their TSH is too low, indicating they are getting too much thyroid hormone. The explanation of this is just normal aging. After a certain time, we need to reduce the dose a bit. That is why it is so important to check your thyroid blood test (TSH) at least once a year, if you're taking thyroid medicine. Then check it again 6-8 weeks after any dose change, suggest the editors of <u><i>Prescriber's Letter</i></u>.</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>FISH OIL TO LOWER YOUR TRIGLYCERIDES</b>: The rule of thumb is that 1 gram a day of omega-3 fatty acids from fish oil will lower triglycerides by 5 to 10%. You can go up to 4 grams a day, if you're not having side effects. </span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>THE NEW DRUG FOR ATRIAL FIBRILLATION</b>: <b>Pradaxa (dabigatran) Can Replace Warfarin: </b>Pradaxa is generally very good news. It is more effective at preventing strokes than warfarin (Coumadin) and it does not require any blood testing. It costs about $240 a month (for twice daily dosing) compared to about $80 (with blood testing) for warfarin. There are, however, a few caveats:</span></div><div class="separator" style="clear: both; text-align: left;"></div><ol><li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">If you are already on warfarin and want to switch to this, you should stop your warfarin, <span class="Apple-style-span" style="color: blue;"><b>wait until your INR is less than 2.0</b></span>, then start the Pradaxa.</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">If you are doing well on warfarin, don't change. Changing will create an increased risk of bleeding, particularly gastrointestinal bleeding.</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Missed doses of Pradaxa: Pradaxa lasts in the system for about 15 hours. Thus <span class="Apple-style-span" style="color: blue;"><b>if you miss a dose, you should take the missed dose as soon as you remember it, but NOT if your next dose is due in less than 6 hours.</b></span> That would increase the risk of bleeding.</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">If you do experience bleeding on Pradaxa, the old remedy of vitamin K which we use for excess bleeding due to warfarin, will <u>not </u>work. You will need a blood transfusion.</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Pradaxa is only good for 30 days after the bottle is opened. </span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The most common side effects of Pradaxa is upset stomach. Taking it with food, or with an OTC medication like Prilosec or Pepcid or Zantac may help.</span></li>
</ol><br />
<div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br />
</b></span></div><div class="separator" style="clear: both; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>Reference: </b>Prescriber's Letter, Vol 18 No 1 January, No 6 June, No 7 July, and No 11, November 2011 </span></div><div style="text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br />
</b></span></div>Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com2tag:blogger.com,1999:blog-340176576888120508.post-32911635449969161432011-10-07T09:08:00.000-07:002011-10-09T22:47:52.875-07:00PROSTATE CANCER SCREENING IS OUT!<div style="text-align: center;"><b><span class="Apple-style-span" style="font-family: 'Trebuchet MS',sans-serif;">THE VIEW FROM THE OFFICE</span></b></div><br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhjx_PsOfNs8mxbZFGprAUO8mgpnwafDcMWsBYOKNUOcgkwhkGVWHgPibgoU01cc33IQUzJU-7Xoyau49Fryf7O2RWgOIR9RaZ30hNuW6fVroZfeyKFuna9DJuu7j38Bg72_pT_or2KESE/s1600/Portola+View+from+the+Office.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhjx_PsOfNs8mxbZFGprAUO8mgpnwafDcMWsBYOKNUOcgkwhkGVWHgPibgoU01cc33IQUzJU-7Xoyau49Fryf7O2RWgOIR9RaZ30hNuW6fVroZfeyKFuna9DJuu7j38Bg72_pT_or2KESE/s320/Portola+View+from+the+Office.jpg" width="320" /></a></div><br />
<br />
<br />
<div class="separator" style="clear: both; text-align: center;"></div><div class="separator" style="clear: both; text-align: center;"></div><div class="separator" style="clear: both; text-align: left;"></div><div style="text-align: center;"><b><span class="Apple-style-span" style="font-family: 'Trebuchet MS',sans-serif;">The United States Preventive Services Task Force (USPSTF)<br />
Will Advise Against Routine Prostate Cancer Screening</span></b><br />
<b><span class="Apple-style-span" style="font-family: 'Trebuchet MS',sans-serif;"><br />
</span></b></div><div style="text-align: center;"></div> <span class="Apple-style-span" style="font-family: 'Trebuchet MS',sans-serif;">The U.S. Preventive Services Task Force has concluded that healthy men should <u>not</u> undergo routine prostate-specific antigen (PSA) testing, the </span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS',sans-serif;"> The recommendation, which will be made available for public comment next week, was based on an analysis of five trials and applies to men of all ages. The <i>Times</i> quotes the task force's chairwoman: "Unfortunately, the evidence now shows that this test does not save men's lives ... <u><span class="Apple-style-span" style="color: blue;"><b>This test cannot tell the difference between cancers that will and will not affect a man during his natural lifetime.</b>"</span></u></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS',sans-serif;"><br />
</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS',sans-serif;"><u>In 2008, the USPSTF recommended against PSA testing in men aged 75 or older</u>, and said evidence was insufficient to recommend for or against testing in younger men.</span><br />
<br />
<div style="margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; padding-right: 20px;"><span class="Apple-style-span" style="color: #0054a6; font-family: 'Trebuchet MS',sans-serif; font-size: x-small;"><i> Read the full story in the New York Times <a href="http://www.nytimes.com/2011/10/07/health/07prostate.html?_r=1&scp=3&sq=prostate%20cancer&st=cse">here</a>. </i></span><span class="Apple-style-span" style="font-weight: normal;"><br />
</span></div><br />
<span class="Apple-style-span" style="font-weight: normal;"><a href="http://www.nytimes.com/2011/10/07/health/07prostate.html?_r=1&scp=3&sq=prostate%20cancer&st=cse">http://www.nytimes.com/2011/10/07/health/07prostate.html?_r=1&scp=3&sq=prostate%20cancer&st=cse</a></span><br />
<br />
<span style="font-family: "Trebuchet MS",sans-serif;">As Jerome Groupman says in his new book ("</span><i style="font-family: "Trebuchet MS",sans-serif;">Your Medical Mind</i><span style="font-family: "Trebuchet MS",sans-serif;">"), to make a reasonable decision on screening, you have to look at the numbers. "Prostate cancer is slow-moving; more people die with it than from it. According to one 2004 study, <b><span style="color: blue;">for every 48 prostate surgeries performed, only 1 patient benefits--the other 47 patients would have lived just as long without surgery</span></b>...Moreover, the 47 who didn't need the surgery are often left with an array of unpleasant and irreversible side effects, including incontinence, impotence and loss of sexual desire. <b><span style="color: blue;">The likelihood of one of these side effects is over 50%--24 of our 47 will have at least one. This means a patient is 24 times more likely to experience the side effect than the cure</span></b>...Returning to prostate surgery, consider that 6 weeks is the advised recovery period. Coincidentally, the operation will, on average, add 6 weeks to your life. (This averages across the 47 people who had no benefit from the operation and the one person who did.) To my way of thinking, the decision then becomes this: When do you want to 'spend' those 6 weeks? When you're relatively young and feeling well, or at the end of your life, when you're old and only dimly aware of your surroundings?</span>"*<br />
<br />
* Quotation taken from the Daniel Levitin, "Heal Thyself," <i>New York Times Book Review</i>, Sunday, October 9, 2011, pp28-29.<br />
<div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS',sans-serif;">COMMENT: As I have previously reported, I do not recommend this test and do not get it for myself. <span class="Apple-style-span" style="color: blue;">The test cannot tell which men will have a problem with their prostate cancer and which will not. This is the only information we really want to know</span>. There are new tests under development, maybe one of them will provide a better option</span>. <span class="Apple-style-span" style="font-family: 'Trebuchet MS',sans-serif;">I have already had patients asking me about the <a href="http://www.sciencedaily.com/releases/2011/08/110803143132.htm">new urine test for prostate cancer</a>, which is still in the research phase and is not yet commercially available. Another link to information on this test can be found <a href="http://www.dailymail.co.uk/health/article-1361832/prostate-cancers-reliable-test-Urine-screening-detects-50-cases.html">here</a>.</span><br />
<div class="separator" style="clear: both; text-align: left;"><br />
</div>Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com3tag:blogger.com,1999:blog-340176576888120508.post-70649454057972343462011-10-06T10:43:00.000-07:002011-10-06T10:43:53.984-07:00<div style="text-align: center;"><b><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">WHEN TO GET A PNEUMONIA VACCINE</span></b></div><div style="text-align: center;"><b><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></b></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhjx_PsOfNs8mxbZFGprAUO8mgpnwafDcMWsBYOKNUOcgkwhkGVWHgPibgoU01cc33IQUzJU-7Xoyau49Fryf7O2RWgOIR9RaZ30hNuW6fVroZfeyKFuna9DJuu7j38Bg72_pT_or2KESE/s1600/Portola+View+from+the+Office.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhjx_PsOfNs8mxbZFGprAUO8mgpnwafDcMWsBYOKNUOcgkwhkGVWHgPibgoU01cc33IQUzJU-7Xoyau49Fryf7O2RWgOIR9RaZ30hNuW6fVroZfeyKFuna9DJuu7j38Bg72_pT_or2KESE/s320/Portola+View+from+the+Office.jpg" width="320" /></a></div><div style="text-align: center;"><b><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></b></div><div style="text-align: center;"><b><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">THE VIEW FROM THE OFFICE</span></b></div><div style="text-align: center;"><b><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">(FIRST SNOW: OCTOBER 6TH, 2011)</span></b></div><div style="text-align: center;"><b><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></b></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>WHO SHOULD GET A PNEUMONIA SHOT (PNEUMOCOCCAL VACCINE) AND WHEN? </b>This is just a brief note to clarify this question. There are separate recommendations for children and adults.</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> For <b>children</b>, the recommendations are to do <span class="Apple-style-span" style="color: blue;"><b>primary immunizations at 2 months, 4 months, 6 months, and a booster immunization any time between 12 and 18 months</b></span>. This immunization in children is clearly and highly effective. It has dramatically reduced the rates of meningitis, pneumonia, infected arthritis, and high fever in children without an obvious source. This vaccine and the H Flu vaccine are the primary reasons why we almost never see meningitis any more. This is the standard recommendation for healthy children.</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> For <b>older children</b> the guideline calls for performing a primary vaccine series in any individual who has <span class="Apple-style-span" style="color: blue;"><b>any kind of immune deficiency or chronic cardiorespiratory condition</b></span> (like cystic fibrosis or congenital heart disease); for a<b>dults under the age of 65</b> a single dose of the vaccine is recommended for persons with a <span class="Apple-style-span" style="color: blue;"><b>chronic cardiorespiratory or immune condition</b></span> with a <b><span class="Apple-style-span" style="color: blue;"><u>single booster shot 5 years after the first</u></span></b>. </span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> One example of a chronic immune condition is someone who has been in a bad accident and ruptured his/her <b>spleen </b>with the result that it has to be <b>surgically removed</b>. The spleen is a major organ of the immune system which protects against severe bacterial infections. So that anyone who has had their spleen removed for any reason should get a primary series of pneumococcal immunizations; they should also receive immunizations against the <b><i>H Flu</i></b> germ and the <b>meningococcal </b>germ. Also any individual who has a chronic cardiac or respiratory condition should receive the pneumococcal vaccine because the occurrence of pneumonia with a weakened lungs or heart could be fatal.</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> For young and older <b>adults <u>under the age of 65</u></b> pneumococcal vaccine, in a single dose, is recommended for patients with cardiorespiratory conditions. These include: <span class="Apple-style-span" style="color: blue;"><b>asthma, smoking, emphysema, and any form of heart disease</b></span>.</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> For <b>ADULTS</b>, the recommendation is simpler. <span class="Apple-style-span" style="color: blue;"><b>All healthy adults should receive a pneumococcal vaccine at age 65. </b></span>If you receive it at age 65 and are otherwise healthy, you only need to receive this single vaccine. You do not need a booster. <span class="Apple-style-span" style="color: red;"><b>For some reason that I cannot readily explain, a majority of older people in the Portola-Graeagle area believe they need routine pneumonia boosters every 5 years. This is NOT the case</b></span>.</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> There are two groups of <b>adults</b> who need pneumococcal boosters <b><u>after age 65</u></b>:</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> (1) <span class="Apple-style-span" style="color: blue;"><b>Any healthy adult who received their initial pneumonia shot <u>before the age of 65</u></b></span> is recommended to get <span class="Apple-style-span" style="color: blue;"><b>just one booster 5 years after the first</b></span>.</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> (2) <span class="Apple-style-span" style="color: blue;"><b>Any adult who has a chronic immune system problem</b></span> (examples include patients on long term systemic cortisone medications, on dialysis from chronic kidney failure, or who have received any organ transplantation, or who have cancer receiving chemotherapy, or who have HIV infection, or who have had their spleen removed) need to get a<span class="Apple-style-span" style="color: blue;"><b> single booster 5 years after the first</b></span>. The experts do not recommend repeated pneumococcal boosters for anyone.</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>SUMMARY</b>: <span class="Apple-style-span" style="color: blue;"><b>Pneumococcal vaccine is recommended for</b></span>:</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> 1. Healthy children at 2, 4, 6, and 12-18 months.</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> 2. Any older children with chronic immune or cardiorespiratory problems.</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> 3. For all adults <b><u>under 65</u></b> who have a chronic immune or cardiorespiratory problem.</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> 4. For <b><u>all healthy adults at age 65</u></b>.</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> 5. A <span class="Apple-style-span" style="color: blue;"><b>single booster shot is recommended 5 years after the first immunization</b></span> for:</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> a. Healthy adults who <b><u>received their pneumonia shot before the age of 65</u></b>.</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> b. For all adults who have a <b><u>chronic cardiorespiratory or immune condition</u></b>.</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> </span></div>Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com1tag:blogger.com,1999:blog-340176576888120508.post-76898222525353840022011-09-16T17:20:00.000-07:002011-09-16T17:20:39.664-07:00Chronic Medication is Not the Answer for Chronic Pain<div class="storytitle"> <div class="separator" style="clear: both; text-align: center;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; font-size: large;"><b>A VIEW FROM THE OFFICE</b></span></div><div class="separator" style="clear: both; text-align: center;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhy_Y8APYqAUNVk4ZIX8xlZ4zoO5Wz5EUwPNlvzyArtHk_iDWuzZp2pqofoc6aoiABhVOQhB1FJCZT-GPgNhcn8XJUjjQxr3AAGNTqAj0_YHC9qFuD-wP-VlbJKhDgtpSpVFVMJVsE3tw/s1600/Portola+Over+the+Bridge.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhy_Y8APYqAUNVk4ZIX8xlZ4zoO5Wz5EUwPNlvzyArtHk_iDWuzZp2pqofoc6aoiABhVOQhB1FJCZT-GPgNhcn8XJUjjQxr3AAGNTqAj0_YHC9qFuD-wP-VlbJKhDgtpSpVFVMJVsE3tw/s320/Portola+Over+the+Bridge.jpg" width="320" /></a></div><h1><br />
</h1><h1 style="text-align: center;">Doctors Call For Pullback </h1><h1 style="text-align: center;">On Narcotics For Chronic Pain</h1><div>Courtesy of NPR:<a href="http://www.npr.org/blogs/health/2011/09/16/140540259/doctors-call-for-pullback-on-narcotics-for-chronic-pain?ft=1&f=1001"> http://www.npr.org/blogs/health/2011/09/16/140540259/doctors-call-for-pullback-on-narcotics-for-chronic-pain?ft=1&f=1001</a></div><div><br />
</div></div><!-- END CLASS="STORYTITLE" --> <div class="postcontent"> <div class="story"> <div class="storylocation" id="storybyline"> <div class="bucketwrap byline" id="res140540261"> <div class="byline">by <span>Scott Hensley</span></div></div><!-- END CLASS="BUCKETWRAP BYLINE" ID="RES140540261" PREVIEWTITLE="BYLINES" --></div><!-- END ID="STORYBYLINE" CLASS="STORYLOCATION" --> <div class="storyinnerwrap"> <div class="postinfo"> <div class="timestamp">05:26 pm</div><div class="datestamp">September 16, 2011</div><div class="datestamp"><br />
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</div></div><div class="storylocation" id="storytext"> <div class="bucketwrap photo300" id="res140546255"><div style="text-align: center;"><img alt="Painkillers like these being counted at the Oklahoma Hospital Discount Pharmacy in Edmond, Okla., need to be used far less often, some prominent doctors say." class="img300 enlarge" src="http://media.npr.org/assets/img/2011/09/16/hydrocodone_vert.jpg?t=1316208162&s=2" title="Painkillers like these being counted at the Oklahoma Hospital Discount Pharmacy in Edmond, Okla., need to be used far less often, some prominent doctors say." width="300" /></div><div class="captionwrap enlarge"><span class="creditwrap"><span class="credit">Sue Ogrocki</span>/<span class="rightsnotice">AP</span></span> <br />
Painkillers like these being counted at the Oklahoma Hospital Discount Pharmacy in Edmond, Okla., need to be used far less often, some prominent doctors say.<br />
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</div><!-- END CLASS="CAPTIONWRAP ENLARGE" --> <div class="enlarge_measure" style="text-align: center;"><img alt="Painkillers like these being counted at the Oklahoma Hospital Discount Pharmacy in Edmond, Okla., need to be used far less often, some prominent doctors say." src="http://media.npr.org/assets/img/2011/09/16/hydrocodone_vert.jpg?t=1316208162&s=51" title="Painkillers like these being counted at the Oklahoma Hospital Discount Pharmacy in Edmond, Okla., need to be used far less often, some prominent doctors say." /> </div><!-- END CLASS="ENLARGE_MEASURE" --> <div class="enlarge_html"><span class="creditwrap"><span class="credit">Sue Ogrocki</span>/</span><span class="creditwrap"><span class="rightsnotice">AP</span></span></div><div class="enlarge_html"><br />
<div class="caption"> In a bracing call to action, three doctors from California are telling their peers to think twice before prescribing potent narcotics for patients with chronic pain.</div></div></div>Drugs such as Vicodin, Percocet and Oxycontin have become among the <a href="http://www.imshealth.com/deployedfiles/ims/Global/Content/Corporate/Press%20Room/Top-line%20Market%20Data/2010%20Top-line%20Market%20Data/2010_Top_Therapeutic_Classes_by_RX.pdf">most prescribed in the country</a>. Between 15 and 20 percent of patient visits with physicians the U.S. include a prescription for an <a href="http://www.nida.nih.gov/researchreports/prescription/prescription2.html">opioid</a>, the modern painkilling medicines whose roots can be traced back to the opium poppy.<br />
But <a href="http://archinte.ama-assn.org/cgi/content/short/171/16/1426">their editorial</a>, published this week in the <em>Archives of Internal Medicine</em>, says there's a troubling shortfall in the evidence to support the use of such drugs for long-term treatment of pain. And, there's ample evidence of harm.<br />
"Unfortuantely, the use of prescription opioids currently results in more deaths in the United States due to intoxication than heroin and cocaine combined," says <a href="http://dhs.lacounty.gov/wps/portal/!ut/p/c1/04_SB8K8xLLM9MSSzPy8xBz9CP0os_hAFz8jl2AXYwN3F2dTAyMXLz9397BgIwMDY6B8pFm8n79RqJuJp6GhhZmroYGRmYeJk0-YJ1C1MQHd4SD78OsHyRvgAI4G-n4e-bmp-pH6UeY47Qk11w_RL8iNMMgyiVQEAEjR3TQ!/dl2/d1/L0lDU0lKSmdvS1VRIS9JSFNBQ0lpTXlDb3FiRURBSUEhIS9ZQTQ1NDUwLTVGMHN0eWp3LzdfUUROMkRTRDMwR0RDNTAyREpOR0dWUzIwVTcvb3M5V0k0MTAxMDAxOS9iZl9hY3Rpb24vZHJrYXR6/">Dr. Mitchell H. Katz</a>, a co-author of editorial, in a <a href="http://archinte.ama-assn.org/content/vol0/issue2011/images/data/archinternmed.2011.213/DC1/katz_091211.mp3">podcast</a>. "That's shocking."<br />
<a href="" name="more"> </a> Doctors' prescriptions for the medicines that are supposed to decrease pain and improve patients' ability to function, he says, are "killing more people than two drugs that we think of as lethal, so much so that they're illegal." The death toll from the legal pain pills is about 12,000 a year, he says. "It's a public health problem."<br />
So what's their prescription? Until there's more scientific evidence, doctors "should not continue to prescribe high-dose opioids" for chronic non-cancer pain. Narcotic drugs for short-term relief of pain are fine, but Katz says there's insufficient evidence to support their use over the long haul.<br />
Instead, doctors should talk with patients about the limits of pain relief and give alternatives to opioid drugs, such as physical therapy or yoga, their due. To some patients, doctors may need to give a sobering message, Katz says in the podcast: "This is not something I'm going to be able to completely take away."<br />
The bottom line of the editorial, part of a series in the journal called "Less Is More," is that a rethink on these narcotics is overdue.<br />
What do the pain specialists think? I asked for a comment on the editorial, and got a statement from <a href="http://www.ohsu.edu/xd/health/services/providers/chour.cfm">Dr. Robert Chou</a>, who heads the group at the <a href="http://www.ampainsoc.org/about/">American Pain Society</a> working on guidelines for clinical practice.<br />
<blockquote class="edTag"> While it's important for clinicians to be more thoughtful about who they prescribe long-term opioids to and to stop opioids when they aren't helping or there is evidence that it is causing problems, the American Pain Society believes opioids have a role in the management of chronic non-cancer pain in carefully selected and monitored patients.<br />
There is evidence from long-term observational studies and evidence coming from some long-term clinical trials that opioids are effective for improving pain in some patients.<br />
For example, we do not believe that a trial of low doses of opioids should be denied to a low-risk woman in her 70's who has severe hip arthritis, who may be able to garden and walk with decreased pain on it.</blockquote><blockquote class="edTag">While the data on overdose deaths and abuse of opioids should concern all members of society, it does not justify an extreme blanket position of no opioids for chronic non-cancer pain.</blockquote><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">My observations:</span><br />
<br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">No one has any objection to treating the acute pain of a sprained ankle, broken bone, or sprained back. These are generally 1 to 2 week situations. Of course, we all know plenty of people who have injured their back and are still taking pain medications 3, 6, 9 months later, perhaps even years later. </span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> If you are an astute observer, what you will notice about these people after 6 months, 9 months, or a year, is that <span class="Apple-style-span" style="color: blue;"><b>they are NOT getting any better</b></span>. If one looks at it from a strictly objective point on view, the common theme to patients who take chronic pain medicines is that they do not get better. To this some will say, "That's no surprise. They have a condition which is just not going to get better." But what the experts have come to learn is that <span class="Apple-style-span" style="color: blue;"><b>the mere fact of taking chronic, usually high-dose narcotics, actually and directly keeps you from getting better</b></span>.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> A lot of this, of course, depends upon how you define "better." The patient in chronic pain may simply prefer to be narcotized and out of it so as not to have to deal with life and his or her chronic pain. But <span class="Apple-style-span" style="color: blue;"><b>pain, whether acute or chronic, is just a small part of life, and life can indeed go on.</b></span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> The real test of the value of a pain medication in chronic use is whether it is helping the patient to achieve any of their well-planned goals and objectives for their life. For example, taking pain medication right before a painful physical therapy session so that you can get through the session and accomplish to work needed to heal is an excellent use of pain medication, no matter how long it goes on. On the other hand, pain medication that keeps you so foggy and energyless that you won't go out to social events, meet with friends, try something new means you're letting the pain medication kill you.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> Thus the usual rule in the context of chronic pain is that <span class="Apple-style-span" style="color: blue;"><b>most pain medications tend to hold you back from getting on with your life</b></span>. <span class="Apple-style-span" style="color: red;"><b>They all do some terrible things to your system. </b></span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> <span class="Apple-style-span" style="color: blue;"><b>Everyone </b></span>who takes chronic pain killers <span class="Apple-style-span" style="color: red;"><b>is going to experience severe constipation, and I mean constipation so severe that stool will be backed up all the way past your rectum, sigmoid colon, transverse colon, right colon, all the way to your appendix</b></span>. This is a very uncomfortable, frankly miserable way to live. You'll be getting cramps every time you want to eat in the advanced condition and then start losing weight.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> Chronic opiates all <span class="Apple-style-span" style="color: red;"><b>have an adverse effect on the cardiac electrical conducting system</b></span>. Methadone is clearly the worst, but they all do it to some extent. They can lead to a condition called <span class="Apple-style-span" style="color: blue;"><b>long QT syndrome</b></span>, <span class="Apple-style-span" style="color: red;"><b>which can be fatal without warning</b></span>. Many experts recommend a <u><b>routine annual ECG</b></u> for all patients on chronic pain medications just to try to detect this condition early.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> The other bad news, particularly for men, is that chronic use of opioid pain medications <span class="Apple-style-span" style="color: red;"><b>leads to lower levels of sex hormones</b></span>. Testicles can start to atrophy; libido goes down; actual serum testosterone levels can go quite low--to low to support adequate sexual function. (This also happens to some extent in women, but the exact effects are not as clear.)</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> So there are lots of reasons not to be very keen to keep using pain medications long after the time of initial injury.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> On the other hand there are a whole host of things that have significant pay-offs. <b><u>Consider some of these</u></b>:</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">meditation</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">yoga</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">vegetarian diet</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">water aerobics</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Sudoku</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">prayer</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">crossword puzzles</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">volunteer activity</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">reading to the blind</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">being a big brother/big sister</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">adopting a child online</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">rescuing a pet</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">try alternative medicine</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">try acupuncture</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">try physical therapy or chiropractic</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">consider non-habit forming pain adjuvants like antidepressants (amitryptyline, nortriptyline), gabapentin, etc.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">pursue a new hobby (like photography, drawing, woodworking, jewelry, etc.)</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">become an expert on some subject of interest to you.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">All of these tend to work towards the development of a better mind. All chronic pain medications work in the opposite direction of numbing your mind and stifling thought and creativity. To go and fulfill your special gift to the world you are going to need an alert open mind, a flexible outlook, and a willingness to try things, anything. If you consciously work on expanding your own possibilities you can build yourself a great palace in the sky and relegate the pain to the hall closet. You just have to think bigger.</span><br />
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</span></div><div class="suppcontent"> <div class="morefrom"> <h3><br />
</h3></div></div><!-- END CLASS="RELATEDCONTENT" --></div><!-- END CLASS="STORYINNERWRAP" --></div></div>Dr Colin Kopes-Kerrhttp://www.blogger.com/profile/11902404650898139292noreply@blogger.com3