In short, researchers assigned 800-some patients to three different diets with varying proportions of fat, protein and carbohydrates. They found that a) patients weren't very good at sticking to the instructions so they ended up eating more similarly than intended and b) people lost weight at the start of diets but then started gaining it back within two years.
So, the good news is that successful weight loss is not complicated (any kind of diet works as long as it's lower in calories), but the bad news is that it's really hard. As an accompanying editorial said, "even these highly motivated, intelligent participants who were coached by expert professionals could not achieve the weight losses needed to reverse the obesity epidemic."
Need some humor after that depressing news? Check out the "Clinical Directions" comments that accompany the study on the Journal's website. Readers offered a number of interesting weight-loss techniques, including eating like a caveman, following the advice of Muhammed, and carrying a tape measure everywhere.
Case in point #1: Docs are required by offical quality indicators to give thrombolytics within 30 minutes of a heart attack patient's arrival. But what if that patient also just suffered a significant head injury? Does the doc try to meet the 30-minute window by skipping the CT scan, thus risking the patient's life if there is internal bleeding? Of course not, says WhiteCoat, but according to Hospital Compare, "my decision made me a bad doctor."
Don't trust everything you read on the comparison site, WhiteCoat concludes.
But how do patients separate the wheat from the chafe?
A new poll by the Harvard School of Public Health finds that the public, while generally aware of the recall, is unaware of its scope. Less than half of those surveyed knew it includes snack bars, pre-packaged meals, ice cream, candy and jars of dry-roasted peanuts.
One big problem is that a lot of these products are the type that will sit on shelves or in freezers for months (or years), and by the time they are used, people will have long forgotten the recall. Providers should encourage patients to search their cabinets and freezers for any products that may contain peanuts, and check them against the searchable, online FDA database of recalled items (Too bad the URL is so unwieldy: www.accessdata.fda.gov/scripts/peanutbutterrecall/index.cfm).
Consumers can also call 1-800-CDC-INFO (1-800-232-4636) for product info.
(The latest figures, btw, show the outbreak has sickened 666 people in 45 states. That's right, 666.)
To wit, for every extra drink per day, the increase in incidence per 1000 women was 11 for breast cancer, 1 for cancers of the oral cavity and pharynx, 1 for cancer of the rectum, and 0.7 each for cancers of the esophagus, larynx and liver. That adds up to 15 cancers per 1000 women, the journal said. Put another way, the authors estimated that about 13% of cancers of the breast, aerodigestive tract, liver, and rectum could be attributed to alcohol, an editorial noted.
The editorial goes on to say: "From a standpoint of cancer risk, the message of this report could not be clearer. There is no level of alcohol consumption that can be considered safe."
Has it come to this: Hesitating at the wine or beer aisle, as you contemplate whether you'd rather have cancer or heart disease? That's being melodramatic, of course, but what should a PCP tell a patient who asks whether she should be drinking a glass of wine a day "for her heart"?
Normally, you could wrap your fish-and-chips in The Sun and that's it, but this made me think of other, more credible reports of genetic mutations that offer evolutionary advantages in humans, specifically their eyesight. Millions of women may have the ability to see an extended range of color--for example, seeing ten colors in a rainbow instead of the seven the rest of us can see. Tetrachromacy, as it's called, is another example of evolution in action. It's been put forth over the years that seeing more colors helps species find riper foods or avoid poisonous ones.
We're in the 150th anniversary of Charles Darwin publishing On the Origin of Species and we're still learning new elements of evolutionary theory and its potential impact on medicine.
The study, which analyzed 233, 537 medication safety alerts generated by 2,872 clinicians in three states in 2006, found that a majority of clinicians bypassed most high-severity DDI and allergy alerts. Researchers concluded that the current warning system falls short of providing meaningful patient protection.
But WhiteCoats counters that since there hasn't been a flood of adverse outcomes reported, maybe the warnings are overblown. Alerts lose power when too many turn out to be theoretical dangers that don't apply to actual individual patients. What do others think? Are electronic reminders of DDIs helpful or just more annoying pop-ups?
Researchers studied 62 patients with implantable cardioverter-defibrillators who underwent monitoring during a mental stress test that asked them to recall a recent situation in which they were angry.
Researchers measured the patients' T-wave alternans (TWA) and then followed them for a mean of 37 months to determine who had arrhythmias that triggered their pacemakers. Patients with higher levels of anger-induced TWA were more likely to trigger their pacemakers--a predictor of heightened risk of up to ten times that of other patients.
Combining exercise tests with mental stress test may help clinicians better select patients likely to have arrhythmia and benefit from a defibrillator, and it might provide insight for patients who can't exercise, researchers wrote in the Journal of the American College of Cardiology.
Naturally, therapies focused on helping patients deal with anger and other negative emotions may help reduce arrhythmias and, therefore, sudden cardiac death in certain patients. It's not the first time anger's been linked to heart disease, but researchers said we are beginning to understand how anger and other types of mental stress can trigger potentially lethal ventricular arrhythmias.
In other bad-but-perhaps-already-known news for women, a group of public health investigators have determined that tobacco companies are trying to make cigarettes appealing. To quote HealthDay again, cigarette ads "depict cigarette smoking as feminine and fashionable rather than the harmful and deadly addiction it really is."
And while we're on the subject, we've got to mention this study, even though its conclusions are far from obvious. A signficant proportion of surveyed smokers said that while the effects of smoking on their own health are not sufficient motivation to quit, they would stop smoking if they knew their pets were being harmed by the habit. Really, people? Really?
Food studies are a staple (pun intended) of medical conferences, and International Stroke Conference 2009 is no exception. As usual, tea and coffee are front and center in the research, though fast food gives them a run for their money. Without further ado:
--Three cups of green or black tea per day lower one's risk of ischemic stroke by 21%, according to a meta-analysis of tea studies from around the world. Pooled results of the 10 studies that examined tea consumption and ischemic stroke found black tea reduced risk by 24%, and green tea by 21%.
--Lest you think you need to swap your morning cuppa joe for tea, take heart: Coffee is also associated with reduced stroke prevalence, an analysis of national health survey data (NHANES III) found. The more you drink, the lower your risk--despite the fact that many heavy coffee drinkers also smoke. Stroke prevalence went from 5% for those who drank 1-2 cups per day, to 2.9% for those who drank more than six cups a day. Cardiac disease, diabetes and hypertension also declined as cups of coffee went up. Could it be that the fountain of youth spurts coffee instead of water?
--To avoid temptation, you might want to skip buying that coffee (or tea) at a fast food restaurant: People who live in neighborhoods with lots of fast food restaurants have a higher stroke risk. Specifically, for each fast food restaurant in a neighborhood, the relative risk rose by 1%. Authors cautioned that this is a correlation--they don't know if the fast food causes the higher risk, or if fast food restaurants are merely a marker of unhealthy neighborhoods. Admittedly, these results seem sort of obvious, but it's interesting that they held up even after researchers controlled for demographic and socioeconomic factors.
Researchers reviewed data on 57 stroke patients, age 16-50 years, from the Young Stroke Registry at Wayne State's Comprehensive Stroke Center, and found 14% were misdiagnosed and sent home. They were told they were having vertigo, or migraine, or alcohol intoxication, but were later found to have had a stroke.
The study didn't compare this rate of misdiagnosis to that of a more typical (i.e., older) stroke population, but some of the specific examples are chilling. An 18-year-old guy was told the numbness on his left side was due to being drunk; a 37-year-old who had trouble speaking was told she was having a seizure; and a 48-year-old with blurred vision, an off-balance walk and trouble speaking was told she had an inner ear disorder.
Separately, stroke survivors are more likely to fall if they have impaired mobility, have a history of falling, and are still experiencing pain and injury from a previous fall...versus people who can get around just fine, haven't ever fallen, and are feeling healthy to boot. Also, older stroke survivors are more likely to fall than younger ones.
And finally, stroke patients who have heart failure are more likely to die in the hospital than stroke patients without heart failure. (I'm going to go out on a limb and say that adding a serious condition to anyone's health profile is, most likely, going to put her at a disadvantage vs. someone without that extra condition.) Stroke + heart failure patients also stayed in the hospital longer and required more intensive care than those with stroke alone.
--Research on depression in caregivers of patients with dementia suggests that Asian and Hispanic American caregivers are more prone to depression than whites, while African American caregivers are less prone to it. One study on stroke patient caregivers found African American caregivers had a 3.7 times lower risk for depression than whites.
--There is some evidence that genetic differences in ethnicities may affect both the likelihood of getting depression and response to treatment, but it's complicated. Several genes seem to be involved, such that a mutation in any single gene accounts for only a small portion of the disease risk.
--There is some evidence that while somatic symptoms of depression may be the same between cultures, cognitive symptoms may be different. For example, Westerners are more likely to report psychological symptoms than the Chinese. Treatment response appears to be the same among different cultures, however.
Several studies were presented at Stroke 2009 today on gender differences in stroke. Here are summaries of two, with more to come:
--A meta-analysis of 18 studies, presented by Archit Bhatt, MD, found that women with acute stroke have 30% lower odds of getting tPA treatment than men. When the analysis pulled out four studies that specified the patients had arrived at the hospital within the 3-hour tPA window, women were still 19% less likely to get treatment--but the difference was no longer statistically significant.
--Louise McCullough, MD, et al reported her findings that women arrived at the emergency department of a single stroke center later than men, despite having strokes of similar severity. Yet unlike Dr. Bhatt's study, Dr. McCullough found that, once the women got to the ED, they were treated just as quickly and often as men. She suggested a number of reasons why women may arrive at the ED later, including the fact that women may not be recognizing their stroke symptoms, or are more likely to be older/living alone when having stroke (thus an observer may not be around to help them get to the ED).
These results are interesting in tandem. Clearly, if women get to the ED later, they are less likely to be eligible for tPA (due to the three-hour time window), which could partly explain Dr. Bhatt's finding that women are less likely to get tPA than men.
The take-home message for internists, I think, is to really hammer home those stroke signs and symptoms with patients, particularly those who are at high risk.
These folks gave a talk to media and bystanders, complete with ambulance and stretcher props, about San Diego's emergency stroke response system. To hear them tell it, a call to 9-1-1 sets into motion a highly choreographed series of events-- a neurologist being paged, a radiologist securing a machine for imaging, a nurse clearing a bed for possible admission, so that everyone is ready to go when the patient arrives. Of course, one would like to think this happens everywhere, but there are many areas of the country which don't have well-oiled stroke plans.
I was a little disappointed that we didn't get a tour of the ambulance-- or better yet, a quick spin through town-- but left feeling that, if I had to have a stroke somewhere, San Diego seems like a good place to do it. (Admittedly, I say this having no real sense of how this city stacks up vs. other places in overall stroke care. And having no real desire to have a stroke, ever.) California in general seems committed to a tidy stroke response, according to Dr. James Dunford, the city's emergency medical director: There's a statewide task force underway to help all of the state's communities develop organized stroke response plans, he said.
(Pictured left to right: Dr. Patrick Lyden, medical director of UCSD Stroke Center; Dr. James Dunford, emergency medical director for the city of San Diego and an emergency department doctor at UCSD; and Vicky Powell, a stroke survivor who benefitted from UCSD's emergency response system.)
Catalina Ionita, MD, University at Buffalo Neurosurgery, Inc., compared outcomes of thrombolyzed stroke patients at a telemedicine "hub" hospital (Millard Fillmore Gates Hospital in Buffalo, NY), with those of the 10 "spoke" hospitals it served. While there were some differences in terms of length of stay and stroke severity, the clinical outcomes were basically the same for patients treated at both-- suggesting that access to a top-notch stroke team via telemedicine is essentially as good as being seen by one personally.
A second study gave a boost to the growing practice of "drip and ship", whereby patients get tPA treatment at a community hospital, and are then transferred to a regional stroke center for follow-up care. Outcomes were similar for patients given tPA at community hospitals and then transferred, vs. those given tPA at the regional stroke center from the start. That's good news, since the alternative to drip and ship is to immediately transfer a community hospital patient to a regional center for tPA, which can be problematic given the 3-hour window for administering the treatment.
Dr. Jeffrey Saver, director of UCLA's Stroke Center, reported on his huge registry study which found that patients who arrived at hospitals within an hour of stroke symptom onset were more than twice as likely to get tPA as those who arrived in the second or third hour. About 30% of the 100,000+ patients studied arrived within that first hour.
The bad news, however, was that doctors took 15 minutes longer to actually treat these first-hour patients than those who arrived later, perhaps thinking they had a bit of a time cushion to ensure that treatment was the right decision. Current guidelines recommend a "door to needle" time for tPA of 60 minutes from hospital arrival-- and for these patients, the average time was 90 minutes.
"There's a natural tendency for physicians to say we have some extra time to learn about the nature of stroke and make a more deliberate decision...but we are trying to highlight (that for) patients who get to hospitals early, we need to match that effort, and treat those patients more quickly," Dr. Saver said. "For every ten minutes that tPA is delayed, one less patient benefits from it."
The surgeon's musings during the operation were dutifully recorded in real time on Twitter by the chief resident. "Tweeple" (Twitter users) worried along with the surgical team when the surgeon announced that the tumor was larger than expected and may require a radical nephrectomy. Everyone breathed a collective sigh of relief after bleeding was controlled and a successful partial nephrectomy accomplished.
The surgeon said he agreed to Twitter because he wanted to show that a tumor could be removed without taking the entire kidney. Other Twitter enthusiasts say it engages people in medicine and makes complicated procedures more understandable. But is Twittering for everyone or is it an example of social networking run amok?
First, Zagat announced their expansion from restaurant-rating to doctor-rating. According to the NY Times, patients insured by WellPoint (in certain areas) will be invited to rate and comment on their doctors through a Zagat site (viewable only by other WellPoint insureds). Not surprisingly, the announcement didn't attract a lot of positive feedback from physicians. Who wouldn't rather take their job pass/fail?
More likely to please docs was the news that Obama's stimulus bill includes funding for comparative effectiveness research. Up to 15 employees and $1.1 billion will be allocated to reviewing existing research and conducting new comparison trials of various treatment options. Sounds like some grades that could be pretty useful, although critics worry that it's the first step toward rationing health care by cost. For more on the stimulus bill's impact on medicine, check out the The ACP Advocate blog.
The database is easy to use, just click on a drug class, such as aminoglycosides or ethambutol, select a gene associated with resistance, and a histogram pops up displaying the mutations and corresponding confidence levels.
The research behind the database is explained in a study by led by Harvard epidemiologists published in the current issue of PLoS Medicine.
Those who blurt out the answers in group setting are seen as more intelligent and competent, even when their answers are wrong. Researchers used this to explain how incompetent bosses survive the workplace. Worse, those who chimed in second or third, even if only to agree with the original wrong answer, were also thought of as more competent (think the office toady who shouts encouragement at a bumbling boss).
Who's right? Hard to say, since no one knows exactly how many more people would sign up for colonoscopies if they had access to the virtual technology. But based on the preliminary CMS decision, it looks like we won't be finding out anytime soon. The agency is accepting public comment for 30 days before making a final ruling on the subject, which experts expect to be against virtual scans.
An article and video in ACP Internist recently assessed (and offered some solutions to) the challenges of getting patients to submit to colonoscopy.
As the NY Times reports today, the International Longevity Center has raised the standard of PC medical language even further by publishing a list of forbidden synonyms for "old." Not only should we not refer to those with more chronological life experience than us as "coots" or "hags," but "elderly" and "senior citizen" are also to be axed. The experts suggest instead the problematically nonspecific (from a medical writer's perspective) term "older adult."
As one commenter to the NYT article noted, would not our effort be better spent trying to correct the pejorative connotations associated with being "elderly" or--to continue the parallel, the negative consequences of being "diabetic"--than repeatedly changing the terminology? After all, how long did it take for "special education" to go from polite euphemism to children's insult?
As the primary care physician shortage worsens, international medical graduates (IMGs) have been critical to filling in gaps in care, especially in underserved areas, according to a CDC report released today.
In 2005-06, one quarter of all visits to office-based physicians were to IMGs, the report says. IMGs also saw a higher percentage of patients using Medicaid or SCHIP as payment compared with their U.S. counterparts and were more likely to practice in shortage areas outside of big cities. However, the report warns that it's getting harder to recruit IMGs to shortage areas because more are coming to the U.S. on less-restrictive visas. The U.S. may face "challenges" if visa policies affecting physician supply remain unchanged, the authors conclude.
With so many new medical graduates rejecting primary care for higher paying specialties and communities struggling to attract primary care docs, should we go back to forcing IMGs to practice in underserved areas as a condition of their visas? Or will the situation force the government to move faster on reforming the dysfunctional Medicare reimbursement system?
Check it out and sign up for the RSS Feed. ACP Internist is slated to guest host the March 17 edition.
Studies about weight typically focus on how to lose it, but a recent study in Spain reveals that fat is sometimes coveted in the world of professional sports.
Researchers at the University of the Basque Country hypothesized that top-flight soccer players are generally more satisfied with their body images than other young men, according to a news release from Spain's Scientific Information and News Service. Predictably, a control group of university-age men said they'd like more muscular bodies but another group of Spanish League soccer players said that while they always try to build muscle they'd also like to add body fat in order to look more like other young men their age. Goes to show that the grass is always greener...
Turns out fat can also help you look younger, according to a new study of identical twins. After age 40, twins who had substantially higher BMIs than their identical sibling also had much younger looking faces.
Further confirming that they are not familiar with actual human behavior, the researchers also attempted to analyze the "five-second rule" of eating food off the ground. Kindergartners everywhere are eagerly awaiting follow-up research to confirm precisely when dropped food becomes too dirty to eat.
In light of those findings, it's fitting that American Society of Clinical Oncology has come out with practical financial guidance for cancer patients. The group's Cancer.Net Web site now has a section about managing the cost of cancer care, including suggested questions to ask your doctor and other professionals. Beyond the strictly medical treatment and medication-related questions, the site lists issues to consider surrounding transportation, living expenses, long-term care and employment issues, for example, as well as a list of organizations that offer financial support to cancer patients.
It's a nice resource for physicians to recommend to patients burdened by financial worries related to their illness.
--Random House Dictionary, 2006
Every day when I come to work, my email inbox is flooded with more product recalls from the FDA, thanks to those darn salmonella-tainted peanuts. The vast number of products supplied by the Peanut Corp of America plant amazes me: they range from store-brand ice cream to high-end "organic" protein bars.
Huh. I never realized the "organic" label referred to animal feces. Though I suppose that is just about as organic as it gets.
--Undergrads who play a lot of video games are isolated and don't have great relationships with their peers or families, a study in the Journal of Youth and Adolescence finds. They are also more likely to smoke pot than those who don't play.
--Songs can evoke memories, researchers trumpeted in the Psychology of Music journal. It doesn't matter whether you hear a snatch of a song, see a picture of the song artist(s) or read the lyrics-- all function equally well at triggering memory.
So let's try this out. Here's the song: "1999" by Prince. Any memories springing up out there?
--High-schoolers who watch too much TV are likely to develop bad eating habits, researchers reported in the International Journal of Behavioral Nutrition and Physical Activity. The study of 2,000 high- and middle-school students also pointed out that TV ads might influence students to make bad food choices. (So that's why they ditched their morning oatmeal for a bowl of triple choco-marshmallow puffs!)
--The expectation of post-operative pain directly correlated with the actual incidence of pain following foot and ankle surgery. Researchers thought that, "Believing there will be pain after surgery leads to just that, pain." They continued that cancer patients who have a more optimistic outlook experienced less severe pain.