The Case for Drinking (All Together Now: In Moderation!)

Thirty years of research has convinced many experts of the health benefits of moderate drinking for some people. A drink or two a day of wine, beer or liquor is, experts say, often the single best nonprescription way to prevent heart attacks ? better than a low-fat diet or weight loss, better even than vigorous exercise. Moderate drinking can help prevent strokes, amputated limbs and dementia.

But moderate drinking also comes with some health risks, such as a slightly increased risk of breast cancer in women. And heavy drinking is accompanied by a such a fearful range of illness and catastrophe that policy makers seeking to create coherent health recommendations for the use of alcohol are stymied.
Should major diet and lifestyle recommendations actually begin to endorse moderate drinking, defined as one or two alcoholic drinks a day?

Thirty years ago, health officials were so uncomfortable with this idea that a federal agency tried to suppress early data on alcohol's beneficial effects. Now, with the data long out of the bag, policymakers say this may be one of the few areas in medicine where general recommendations are simply not possible and individual doctors and patients will have to make decisions on their own.

Most physicians dance around this one. Despite overwhelming evidence that 1 drink a day (perhaps a nightly glass of wine) decreases mortality (especially heart disease and stroke), physicians fear recommending alcohol because of the risks of heavy drinking.

I will go out on a limb here. I do recommend moderate drinking. One or two drinks a day (no more) are appropriate for men after 40 and women after 50. While I recommend it, I have not done it myself (drinking about twice each week). Perhaps I should make this a New Year's resolution - one glass of wine each evening. I will let you know.

I personally find this story sad, but not surprising. Jeffco pulls plug on health plan for poor : Preference for ERs doomed project

A three-year test project trying to get uninsured patients out of emergency rooms and into primary, preventive health care has ended a year early because of lack of interest from the people it was supposed to help.

The Coordinated Health System of Jefferson County ended its project called HealthPlus this month and withdrew their last year of funding totaling $150,000 from the Robert Wood Johnson Foundation.

The group a public-private coalition of doctors, hospitals, Jefferson County government and the county Health Department plans to stay together to continue to try to improve health care for the county's uninsured poor.

But few uninsured emergency room patients showed interest in the project that offered follow-up care at public health clinics.
The idea was that many patients could stay out of crowded, expensive emergency departments if they got adequate preventive care. Those who needed treatment from specialists would get referrals from the clinics to private doctors who volunteered with the program, and hospitals would provide free care for hospitalized patients.

I live in Jefferson County, Alabama and am familar with the project and its failure. While I am not surprised by these results, I am saddened.

What does say about the culture of our underprivileged citizens? Why would someone prefer an emergency room? (I try very hard to avoid them)

I must commend the coalition for returning the grant moneys. How can we provide the appropriate medical care to these patients? This story is very depressing.

Each morning, often as I am working on this blog, I consider my plans for the day. What do I want to accomplish? This habit started several years ago, thanks to Steven Covey's 7 Habits of Highly Effective People . While I highly recommend the book (or the audio tapes), this link does a nice job of summarizing the principles in the book - Seven Habits Condensed Summaries. While I have found all seven habits worth considering, today I want to concentrate on the seventh habit - the principle of balanced self-renewal. Quoting the summary:

Suppose you came upon someone in the woods working to saw down a tree. They are exhausted from working for hours. You suggest they take a break to sharpen the saw. They might reply, " I didn't have time to sharpen the saw, I'm busy sawing!"

Habit 7 is taking the time to sharpen the saw. By renewing the four dimensions of your nature - physical, spiritual, mental and social/emotional, you can work more quickly and effortlessly. To do this, we must be proactive. This is a Quadrant II (important, not urgent) activity that must be acted on. It's at the center of our Circle of Influence, so we must do it for ourselves.

The Physical Dimension.

The physical dimension involves caring for your physical body - eating the right foods, getting enough rest and relaxation, and exercising on a regular basis.

If we don't have a regular exercise program, eventually we will develop health problems. A good program builds your body's endurance, flexibility and strength. A new program should be started gradually, in harmony with the latest research findings.

The greatest benefit of taking care of yourself is development of your Habit 1 "muscles" of proactivity.

I will assume that you are one of the many readers who either has committed to exercise or would like to. The LA Times has a well considered piece on keeping your New Year's Resolution on exercise - Resolve all you want, but fitness needs a real plan. This article does not have quick fix ideas, rather it goes through the steps one should take to achieve fitness success.

"People spend an inordinate amount of time planning a trip or a wedding, but when it comes to getting in shape, people are unwilling to plan," says Charles Stuart Platkin, author of "Breaking the Pattern: The 5 Principles You Need to Remodel Your Life" (Red Mill Press, 2001).

That resurrects old patterns and habits that didn't work then and won't work now: "If every year you join a gym but you hate going to the gym, then maybe you need to come up with something else that provides you with cardiovascular and strength training."
Platkin, founder of the Nutricise weight-loss program, suggests rediscovering some long-forgotten but favorite sport, such as racquetball or swimming. If socializing is important, get a workout buddy (preferably one with equal zeal), join a team or make friends at the gym.

If just the thought of setting up an exercise routine seems daunting, break it into manageable steps, says Jerald Jellison, a professor of psychology at UCLA. "If you're going to join a gym, bring a checklist of things you want to know, such as the quality of the instructors, the kinds of classes they offer, and when they're open."

So each morning, as I am considering my day, I think about exercise. Is this an exercise day? If so, where and what are my plans. For example, today I plan to run on my treadmill in the afternoon after work. Yesterday I went to the gym and used an elliptical machine plus I did some leg strengthening work. Tomorrow I will workout with my trainer. This exercise variety - variety in activities and sites - works very well for me. But I must emphasize that I have developed this plan over time, understanding myself, my motivations and my habits.

Each person should find a system that works for them. I know people who do the same routine almost every day. While that system works for them, I would not work for me. Do you need variety or consistency?

Why are you exercising? What are you trying to achieve?

Setting unachievable goals is one way to almost ensure dropping out of a fitness program. Expecting to run a marathon by spring or dropping 30 pounds in a month is unrealistic for most people. Instead, focus on training for a 5- or 10-kilometer run before tackling anything more. Also, replace amorphous objectives with specific ones. Says Maidenberg, "What is the goal and how will you know when you succeed?"

Goals are very helpful. I set modest goals each 2 months. I also have some long range goals that I am working towards. For example, I have used body fat percentage as a goal. One of my two month goals have been to decrease my body fat by at least 1%. I am now nearing my overall goal, and will be resetting my goal towards maintenace.

I also have strength goals. I decided that I wanted to be able to bench press my weight. So I worked with my trainer to develop an exercise plan to achieve that goal (which I achieved 2 months ago). I am working on a long term goal to be able to do pull-ups. We have a plan and work towards that each week.

Often goals remain unattained because people focus only on their ultimate objective, which doesn't come fast enough. Resolutions are broken during the critical first few weeks of a new exercise program, when the pounds haven't come off, abs haven't gone flat, and getting up early and schlepping to the gym is still an excruciating chore. Small victories are frequently ignored, but they shouldn't be.

"Do you feel like you have more energy or can handle daily hassles better?" says Marcus, coauthor of "Motivating People to Be Physically Active" (Human Kinetics, 2003). "Do your clothes feel a little less tight? Do you just feel less bad? Short-term benefits could be having time for yourself to take a class, dance like you don't really get to, socialize and laugh. The fitness part is almost secondary."

Marcus and others advise keeping a diary of not just weight loss or time spent exercising, but also notes about positive changes in mood, sleep habits and overall health. "Write down if you did something active for 10 minutes. Then try to get in two 10-minute sessions. Feeling like you're making progress motivates all of us."

Jellison recommends looking to friends or family for positive feedback, "one or two people who are sincerely interested in the details of your progress," to act as designated cheerleaders.
There's also nothing wrong with a tangible incentive every now and then -- as long as it's not a piece of cheesecake. "When you lose 5 pounds, buy yourself a CD or call a friend," Jellison says.

If you are planning to make a resolution involving weight loss and exercise, really plan. Think through what you are trying to achieve. Break it down into achievable steps and celebrate each attainment. You can achieve amazing things once you understand how to plan each day and work towards each intermediate goal. Good luck and Happy New Year!!!

Doctors angered by letter from Pa.: The state warned them not to abandon patients. Many may quit their practices amid an insurance crisis. So what did this letter say?

The Dec. 20 letter from Secretary of the Commonwealth C. Michael Weaver was sent to all licensed doctors in the state as a "reminder" of their professional and legal obligations to their patients.

The letter arrived as some doctors say they will, at least temporarily, stop practicing medicine as of Wednesday in response to the state's malpractice crisis.

"A stoppage of practice may be detrimental not only to your patients, but also to your practice, your standing amongst colleagues, as well as your license should your conduct be found to constitute abandonment," Weaver wrote.

Weaver's office oversees the licensing and disciplining of Pennsylvania doctors.

When a fire rages, one should not throw oil. This letter brought outrage and dispair from the physician community.

But the letter has generated a firestorm of protest from doctors.

"It is psychologically abusive to have a letter like that come to our homes during the holidays," said Lynette B. Goodstine, a Montgomery County internist.

On Friday, the Pennsylvania Medical Society was inundated with calls and e-mail from doctors infuriated by Weaver's letter.

"Many physicians found the tone of the letter insulting and threatening," said Roger F. Mecum, executive vice president of the Pennsylvania Medical Society, which represents the state's doctors.

"Physicians of this state would like the representatives of our state government to help us solve this problem as quickly as possible, and not point out the moral and ethical obligations of physicians of which they are well aware," Mecum said.

I believe that the country's best hope lies in the Congress. The entire country needs tort reform. This is more than just a physician issue. According to the Washington Post, we should expect progress. GOP Plans New Caps on Court Awards . This article speaks to the large issue of tort reform and includes this about malpractice.

Lott said congressional Republicans early next year will push for legislation proposed by the president that would dramatically limit the liability of physicians sued for medical malpractice. Under the plan, aggrieved patients could seek no more than $250,000 for pain and suffering, even if their state's law permitted a much higher award. There would be no federal limits on compensation for economic damages, such as lost wages and medical costs.

When Bush announced the plan earlier this year, he said the limit was needed to keep doctors from being forced out of business by escalating malpractice insurance costs. Democrats say the $250,000 limit is much too low, particularly for patients whose lives are changed forever by a physician's wrongdoing.

In the last two years, doctors have given the GOP $7.8 million and Democrats $3.8 million, according to the nonpartisan Center for Responsive Politics.

In the past two years how much money have trial lawyers given to each party? I would expect the Washington Post to show more balance here.

For those who want to keep up to date on the problems associated with trial lawyers, I recommend Overlawyered.com. That site does a great job of documenting the problems associated with our current tort system. Meanwhile, things just get uglier in Pennsylvania. Do not be surprised to see an ongoing exodus of physicians.

This author thinks gluttony good! Gobble up: gluttony is the gift of civilisation

Gluttony is a gift of evolution. In the struggle for survival with other animals, human beings have always had two severe disadvantages: feeble bodies and simple digestions. These restrict our cycle of energy production by limiting the range of food sources we can absorb. Big meals are a form of natural compensation, stoking our energy generators with ample fuel. That is why we evolved ways of exciting appetite: ours is the only species which dresses food to make it more appealing to the palate. Our bodies, moreover, are designed to make the most of our excesses by storing the benefits as fat. On average, the body of a normal, healthy person in the developed world contains relatively more fat tissue than that of a penguin or a polar bear. Whereas most animals concentrate their stores of body fat in one or two parts of the body, we have multiple deposits, spread generously all around our frames. Human beings are designed by Nature to be overeating animals.

...

Now, moralists, dietitians, fashion advertisers and lifestyle journalists try to nag us into frugality. I doubt whether even so formidable a combination of forces can reverse evolution and history. Gluttony has a powerful pedigree. Excess at table is hallowed by antiquity. So eat on. Face those leftovers without discouragement: you may feel bloated on Boxing Day, but your struggle with your waistband is part of an historic contest. This is the season, moreover, when supplies are abundant to sustain it and parties come to the aid of all good men.

This ode to gluttony rings with some truth. The author speaks to the evolutionary advantage of storing body fat. But we no longer live in circumstances when the next meals are questionable.

The occasional gluttonous feast is not the problem. I am not such a prude to discourage the occaional feast. The problem stems from a chronic lack of moderation in eating. So eat your feast at appropriate social circumstance, then decrease consumption and increase exercise the next few days to prevent the accompanying weight gain. Gluttony may sound good, but diabetes, hyperlipidemia, hypertension and coronary artery disease (not to mention osteoarthritis) greatly impair ones quality of life!

Frequent readers know of my fitness obsession. I hesistate to provide this link as it trivializes the fitness boom, nonetheless here goes - Body worship by Suzanne Fields.

The new shrines of worship have no steeples, spires or domes, but (stationary) bicycles and treadmills. These are the gyms where the penitents wear workout suits instead of hair shirts. In these worldly temples the craving is physical rather than spiritual, and the sacred icons are barbells, leg curls and chest presses. The flock is made up of men and women who want to change the shape of their lives by changing the shape of their bodies. You might say they're trying to sweat their way to salvation.

  Personal trainers and yoga masters are the leaders in this counter-reformation. An abstract mantra replaces personal contrition and faith in prayer as push-ups and pull-downs give new life to rituals of self-flagellation. Purification through fitness focuses on acts of humiliation commensurate with stress and flab.

   "Like Christian salvation, the holy grails for gym-goers may be distant and unattainable, and the paths towards them painful, but the rules and routines that their pursuit involves seem to provide comfort to a new and growing breed of secular puritans," declares the Economist, the British newsweekly, analyzing the expanding market of gym franchises and health clubs both here and in Britain, whose sponsors promise deliverance through body-building and body worship. Forget the pulls of virtue and sin, yin and yang, karma and nirvana, the polarization after the physical fall from grace is between the fat and the fit.

...

So beware of the New Age snake oil in the Gymnasiums of Eden. Satan can find Eve on a Stairmaster or in a rowing machine and Adam will drink the forbidden fruit juice wherever it's offered. Fitness may be just another fig leaf to hide from our inner selves. It might be better to eat, drink and be merry than to be miserable on the exercise machine. Happy holidays.

This rather cynical commentary misses the point. Hopefully she just rails against those gyms which have become 'meat markets'. The gyms that I frequent are filled with all ages and all shapes. I see people working hard to improve their fitness. And many previous posts have discussed the benefits of improved fitness.

Have you ever made a New Year's Resolution? Did you honor your resolution?

Why are habits so difficult to change? Are there any tricks to help us succeed?

Retraining the brain for New Year?s: How to make sure you keep resolutions once and for all. Here is the punch line, read the article for the details!

Tips for retraining your brain

• Weed 'bad' triggers. If you're trying to quit smoking this New Year's, remove the ashtrays and cigarettes from your home and car. If you're trying to eat less sugar, rid the pantry of sweets, even chocolate baking chips, if they'll trigger you.
• Plant 'good' triggers. Put sugarless chewing gum in the places where your ashtrays used to be. Keep fresh fruit and vegetables in the refrigerator. Place a packed gym bag near your front door.
• Make proclamations. Tell people close to you about the changes you plan to make. Discuss your New Year's resolutions with friends.
• Garner support. Line up a few friends or family members who will agree to cheer you on or just listen to you when you're having a challenging day.
• Keep trying. Giving up a bad habit or developing a good one takes time and hard work. It's common to have a few setbacks along the way. But if you stick with it, over time you're likely to successfully retrain your brain.

It is getting ugly in Pennsylvania. Surgeons threaten walkout over insurance costs.

Claiming high premiums are forcing them out of business, at least 45 doctors in Scranton said they have stopped accepting new patients and won't perform surgeries after January 1. The total includes 10 of the small city's 18 general surgeons, 14 of its 15 orthopedists, and all 8 of its urologists.

"I don't want to be irresponsible. I just want someone to put their feet in my shoes for a while," said Scranton neurosurgeon Shripathi Holla. "We need more people to take care of these patients, and the insurance situation is driving us out of the market."

Doctors have tried mass walkouts elsewhere in the nation.
In Las Vegas, 150 doctors at University Medical Center resigned in July to protest high insurance premiums, prompting the hospital to shut down its trauma center for 10 days.

The action prompted a special session of the Nevada Legislature, which enacted a law capping damages in trauma center malpractice cases at $50,000, except in cases of gross negligence. About half the doctors returned to work after the bill passed.

The American Medical Association, the country's largest physicians group, said that while such mass demonstrations are rare, physician groups have also been forced to shut down in several other states because of high insurance costs.

In Scranton, some are calling the threatened walkout a protest. Others insist it is a simple business decision. Holla said his malpractice insurance costs $450 a day -- a rate he says is strangling his practice and preventing his hospital from recruiting doctors.

Even physicians must make business decisions. One should not expect us to work in a situation which seems hostile. The current malpractice costs help define a hostile environment. This action is undesirable, but I do understand their problem. Please do not just think them greedy. It is much more complex than that.

Disinfectant 'could beat' superbugs. A major health risk of hospitalization comes from highly resistant bacteria. This British news story reports on a new disinfectant that might decrease patient transmission of resistant bacteria.

An extra-strong disinfectant could help hospitals beat superbugs which affect thousands of patients each year. The sterilising liquid is strong enough to clean surfaces and surgical instruments, but it does not harm eyes or skin, and could even be drunk safely.

Its developers, Chester-based Medipure Ltd, say it is better than previous "super disinfectants" because it does not have any hazardous side-effects.

Medipure say their Suprox liquids can kill bugs including E.coli, salmonella and tuberculosis bacterium.

The liquid is a sodium chloride solution which is activated with an electrical charge.

Jim Daly, a chemist and chemical engineer who is leading the research into the super-disinfectant, said the liquid could have many uses.

"We can see so many applications for it, from medical to horticultural and even in animal husbandry."

He told BBC News Online: "It is a very powerful disinfectant which is capable of killing anthrax and it's very useful for sterilising surgical instruments.

"And MRSA would be killed by this technology."

Dr Daly said: "The thing is that you can't become immune to this. It totally destroys the cell wall of the micro-organism, it doesn't just gently affect the DNA."

This sounds like a promising story - as usual the appropriately skeptical reader will await the data!

As Drug Patents End, Costs for Generics Surge

Prices of generic drugs are rising almost twice as rapidly as prices of brand-name drugs, even as many insurers and the Bush administration are pressing Americans to switch in the name of saving money.

The trend is expected to continue over the next few years as a number of enormously popular brand-name drugs lose their patent protection and drug makers introduce generic versions at high initial prices.

This is a disturbing trend which will have a major impact on the cost of health care. Perhaps this trend will stabilize over time.

Israel Will Expand Its Smallpox Vaccinations, but Not to Everyone

Israeli officials said today that they had decided against vaccinating the entire population against the smallpox virus. But they said they were expanding the number of soldiers and health care workers who would be vaccinated to 40,000 or more.

The officials said they made the decision after concluding that the likelihood of a smallpox attack, by terrorists or another country, was slim. A more realistic goal, they said, was to ensure that the country's doctors and nurses could carry out a crash program to inoculate the entire population quickly if a single case of smallpox were discovered. The officials said they hoped they could vaccinate the entire population of six million Israelis in about four days if the need arose.

Israel has given 17,000 vaccinations with 2 recipients and 2 contacts requiring hospitalization. They have had no deaths, but then we only expect 1 death in 1,000,000 vaccinations. No deaths in 17,000 gives us no evidence of the death rate other than it is likely less than 3/17000 = .0176%. We can translate a zero numerator into a confidence interval of less than 3 divided by the denominator. So we should still use the old estimate of mortality.

If Israel thinks that the risk of a smallpox terror attack is very small, why are we diverting resources towards a vaccination policy in this country? Public health dollars are currently a zero sum game. Thus, investing in smallpox vaccination does 2 things: [1] it puts the recipients and their family contacts at some risk; [2] it diverts public health dollars from some other desirable program - Smallpox Plan May Force Other Health Cuts: States Cite Inability To Fund Vaccinations. I remain against this policy until someone can convince me that we have a significant risk. I support having the vaccine ready to go. We should have personnel trained to give the vaccine in the very unlikely event of a true smallpox case.

Drug Makers Battle Plan to Curb Rewards for Doctors.

Drug companies and doctors are fighting a Bush administration plan to restrict gifts and other rewards that pharmaceutical manufacturers give doctors and insurers to encourage the prescribing of particular drugs.

In October, the Department of Health and Human Services said many gifts and gratuities were suspect because they looked like illegal kickbacks. Since then, a few consumer groups, including AARP, have voiced support for the restrictions. But they are outnumbered by the drug makers, doctors and health maintenance organizations that have flooded the government with letters criticizing the proposal.

If this subject interests you, please read the entire article. This article speaks to the dependence of many educational programs on the pharmaceutical industry - including most medical societies. The managed care industry and the pharmaceutical industry also have a major relationship, with incentives to the insurers for using a high percentage of a particular pharmaceutical.

I understand all of the problems, and hope that the government has the courage to tell all to bite the bullet and accept the new rules. They can adjust, and should.

May you and your family have a wonderful holiday season. Thanks for reading my blog. Writing this blog has helped me greatly. I have developed the discipline to think and write about medical issues daily. Thanks to the blog, I read the newspapers, review major journals, and peruse various web sites. I hope that some of my rants help readers, either with new knowledge, or by encouraging them to consider a problem in a different way. As usual, I will make rounds later this morning, and only hope that I can continue to help those in need of care. May the coming year be healthy for you.

Millions of U.S. Smokers Ignore Warnings: Millions of Americans Keep Smoking Despite Doctors' Warnings, Illnesses The story is well known to physicians. I have patients sneak off the floor after a myocardial infarction - to smoke - even when the temperature is in the 30s. I have patients remove their oxygen to go outside to smoke. Nicotine is a horribly addictive drug.

The agency's Dr. Steven B. Cohen said the data will allow researchers to detect trends and determine whether people with chronic illnesses continue to smoke in large numbers in coming years. AHRQ is the government's lead agency for research on health care quality, costs, outcomes and patient safety.

"We're trying to assess the individuals who are current smokers and get a sense of whether, in the past 12 months, they have been advised to quit," Cohen said.

The findings were no surprise to Dr. Norman H. Edelman. "We see people like that all the time," the Long Island physician said.

"What it points out is nicotine is a true addiction, just like being addicted to heroin or cocaine or other narcotics. You are perfectly aware of deleterious effects but it's hard to break an addiction," said Edelman, who teaches at the State University of New York at Stony Brook.

Each day when I make rounds I try to convince patients to stop smoking. I know that I am rarely successful, but sometimes, just sometimes, I make an impact. Even if 5% of my 'lectures' pay off, I have helped someone. If I only knew now to help the others.

Medical Milestones: Remembering the Top Stories of 2002. These are Dr. Tim Johnson's top five - and he seems to have it right. Read and enjoy.

Dutch Doctor Loses Euthanasia Appeal This short article makes my point precisely. So what point is that (the curious reader is asking)?

I am, have been, and will be against active euthanasia. I have read all the arguments in favor, and still believe that physicians should not engage in euthanasia. Here is my argument.

We have an obligation, as physicians, to relieve suffering. That moral obligation must have boundaries. I clearly distinguish between active and passive euthanasia here. Passive euthanasia occurs when we allow nature and disease to take their course. I am not against discontinuing a respirator, or even feedings in a patient who all agree has no probability of recovery. I am not against giving enough narcotic to relieve pain, even if that dose could possibly be fatal. At the same time, I cannot purposely take a single life. To do so starts me down a slippery slope. What criteria do I use to justify euthanasia? How do I decide?

In my mind, and the judges, this physician slid down that slope.

The doctor, who appealed the verdict to test the limits of the law, had helped a man to take his life. The man suffered from incontinence, dizziness and immobility and said he was tired of life; but the court said his condition did not justify a mercy killing, which is legal only if the patient faces intolerable suffering.

Small Amount of Fish in Diet Is Said to Yield Big Benefits

Men who eat seafood as seldom as once a month may cut their risk of the most common kind of stroke by more than 40 percent, a new study by the Harvard School of Public Health has found.

Many studies over the last two decades have found that eating fish reduces the risk of stroke and heart attack. What is surprising about this one is that it shows how little fish - one to three meals a month of virtually any fish or shellfish, like salmon sushi, tuna on rye, broiled lobster or McDonald's Filet-O-Fish - appears to produce the maximum benefit.

"Previous studies found that you had to eat fish once or twice a week," said Dr. Ka He, the Harvard nutritionist who led the study, which was released yesterday by The Journal of the American Medical Association. "And they found a linear association ? the more fish you ate, the more benefit you got. But in our study, we found a threshold. Further fish did not provide further benefit."

This is certainly good news, especially for those men who do not eat fish. They do not have to eat it that often. I assume that almost anyone can find some fish they like. But then I probably eat fish 3-5 times weekly, so I am not test.

This study is probably not the final answer on the fish question. It does provide some simple advice - eat fish occasionally - for men. Women apparently are different.

A Harvard study of strokes among 80,000 female nurses followed for 14 years reported in The Journal of the American Medical Association in January found that women who ate fish five or more times a week had a 52 percent lower risk of stroke than women who ate fish less than once a month. But it found that the relative benefit dropped to only 22 percent for those who ate fish once a week and 7 percent for those who ate fish once a month.

Dr. He agreed that the protocols of the two studies were roughly the same, and he said he could not explain why his study found a threshold level, while the other study found a progressive benefit.

Obviously we need more research here. In the meantime my favorite fish is tuna - either tuna steak, tuna salad, or tuna sushi. I will continue to eat fish on a regular basis. Like my mother's chicken soup - it couldn't hurt!

We have used little spironalactone over the past 30 years. My only regular indication was ascites secondary to cirrhosis. While aldosterone blockade made sense as we learned about the renin angiotensin aldosterone system, the long side effects of gynecomastia and hirsutism (amongst other side effects) limited our enthusiasm.

The RALES study - The Effect of Spironolactone on Morbidity and Mortality in Patients with Severe Heart Failure - changed our thinking. We had to consider the possibility that increased inhibition of the entire system (i.e., ACE inhibitor + ARB + aldosterone antagonist) might convey advantages.

The pharmaceutical industry spotted a niche (and a chance for market share). The FDA has approved eplerenone (to be marketted as Inspra™ - Pharmacia) for treatment of hypertension. Reports suggest that the drug will hit the market in early 2003. Yesterday, Pharmacia submitted further data to the FDA on the effectiveness of eplerenone in post-MI heart failure.

Announcing that eplerenone (Inspra™ - Pharmacia) has successfully met both primary end points in the EPHESUS trial, Pharmacia declared its intention of submitting eplerenone to the FDA for approval in the treatment of post-myocardial infarction heart failure in the first half of 2003.

Eplerenone is a selective aldosterone blocker (SAB) and has been called a "cleaner, safer" version of spironolactone. Analysts have predicted that eplerenone could be a potential "blockbuster" product for Pharmacia. Eplerenone was approved for the treatment of hypertension in September 2002.

The Eplerenone Post-AMI Heart Failure Efficacy and Survival Study (EPHESUS) was a randomized, double-blind, placebo-controlled trial evaluating the use of eplerenone plus standard therapy on survival and morbidity in patients with recent MI who also had early complications of heart failure as identified by left ventricular dysfunction. Primary end points were all-cause mortality and death or hospitalization from cardiovascular causes. The EPHESUS trial was initiated in December 1999 and enrolled 6644 patients at 674 centers in 37 countries.

Pharmacia announced that no further details of EPHESUS would be available until all data analyses are complete and results are presented in a public, scientific forum.

This story comes from theheart.org. Today's story references the story on the FDA approval of eplerenone as an antihypertension agent.

I tremble as I type this. Breast cancer screening may not work as well as we believe. Some experts have believed this since the 1950's. Let me summarize their argument.

What if tumors, as they originally develop, have genetic features which predetermine their aggressiveness (and thus the patients probable outcome)? If that were true, then early detection may not really help anyone. The naysayers believe that hypothesis. And that hypothesis received some support last week.

Nothing Is Black and White in Cancer Detection Debate

Most researchers agree that there are tumors whose fate appears to have been sealed at the time they were found. Yet today that grim reality is discovered only after the fact. A woman will be treated for her cancer with surgery and, often chemotherapy, only to have the cancer recur a few years later, in her bones or brain or liver.

"If you take out a small tumor and get metastatic disease a few years later, chances are that the metastasis was already there when you took out the primary tumor," said Dr. Steven Goodman, a biostatistician in the department of oncology at Johns Hopkins University. "So taking out the primary tumor did nothing." The cancer had already microscopically spread.

The gene activity studies also might help researchers answer another pressing question: Would finding the cancer even earlier make a difference? Do tumors start off lethal or do they grow into lethality, acquiring mutations over time that enable them to kill? And if they grow into lethality, when does the crucial transformation occur?

Last week, in The New England Journal of Medicine, a paper by researchers in Amsterdam gave a taste of the future. It indicated that breast tumors appear to have genetic signatures ? the pattern of activity of 70 genes ? that predict whether a tumor is going to prove lethal, despite treatment, or not. The researchers found signatures in all the tumors they examined, large and small.

Researchers cautioned that such genetic signature studies were fraught with methodological difficulties. This one, while larger than many and avoiding some pitfalls, must be confirmed in studies with larger numbers of women who are followed for years to see if the signature is predictive and, if so, if it is as powerful a predictor as it seems in initial studies.

The signature is not an inherited gene and the study says nothing about whether a woman whose mother, for example, died of breast cancer will be likely to die herself if she develops the disease. Instead, it is a property of the individual tumor in an individual woman's breast that may be a combination of chance mutations with genetic inheritance but whose origins are not yet known.

The Amsterdam study, involving 295 women who had been treated at the Netherlands Cancer Institute, concluded that those whose tumors had good signatures ? a favorable pattern of expression of the 70 genes ? had a 94.5 percent chance of surviving for the next 10 years. Those whose tumors had bad signatures had a 54.6 percent chance of surviving that time period.

These data a sobering. Should we view these data with dispair or hope? I am hopeful for several reasons. If these data are validated over time, we will have much better prognostic information to give our patients. I believe strongly in combining hope with 'straight shooting'.

Moreover, once we understand which women are more likely to have bad outcomes, why can better study why. Oncologists likely will develop different treatment protocols for these women. Researchers will study the genetic signature to find explanations for the aggressiveness of the tumors.

So where does that leave women? Should we bother with mammography? I still believe that mammography should remain part of our screening armamentarium. We must remember that the test is far from a perfect screening test. Yet, it probably does save some lives in the 50 and older patients.

So why even rant on this subject? I subscribe to the principle of continuous re-evaluation of the data. We adopt tests, medications, and technology first on faith, then on the basis of some data. As we collect more data, we must continuously reassess. This article represents another important datum as I (and others) struggle with this most important cancer. If our approach is less effective than we thought, then we must accept the data and move on to another approach. The research cited herein is most important and deserves several validation studies. If you would like to read the original article and have a New England Journal of Medicine subscription - A Gene-Expression Signature as a Predictor of Survival in Breast Cancer I close this rant with a sobering yet optimistic quote from the accompanying editorial.

One must keep in mind that, at the moment, analysis of prognosis based on molecular profiling has been applied only to a specific group of women (those less than 55 years of age with small tumors and either stage I or stage II disease), a group that clearly is not representative of the entire spectrum of patients with breast cancer. Although there is no indication that prognosis profiling would not be equally useful for all patients with breast cancer, we need to validate the results obtained by van 't Veer et al. and van de Vijver et al. in larger groups of patients, which must include older women and patients with more advanced disease. In the study by van de Vijver and colleagues, adjuvant therapy (hormone therapy, chemotherapy, or both) was given to most of the patients with lymph-node?positive cancer. We now need to carry out studies that will allow us to take into account the effect of treatment on disease outcome. Last but not least, we need to evaluate critically whether the analyzed set of predictor genes, which were selected on the basis of analyses of tumors from young patients with lymph-node?negative cancer, can be applied to all patients with breast cancer, or whether there will be a need to refine or expand this list of genes.

The study by van de Vijver and colleagues is an excellent starting point for work aiming to predict the behavior of a tumor. This approach, combined with efforts to create targeted therapies for cancer, will certainly provide new opportunities for the management of cancer.

Drug classes are not always filled with equivalent drugs. The first ACE inhibitor - captopril - has a shorter half life than the rest of the available class, and thus is more difficult to use. One could find many such examples of the first being the least useful. However, when it comes to proton pump inhibitors, it appears that they all work similarly. That is why the release of generic omeprazole (Prilosec) is so exciting. And physicians are responding predictably and prescribing the generic! Generic Drug Prilosec Off to Strong Start in U.S.

Physicians know this, but sometimes forget. Acetaminophen can cause acute liver toxicity at high doses. The danger of acetaminophen.

It has long been known that too much acetaminophen can cause liver damage, but the alarming extent of the problem has just been documented. A new study has found that overdosing on acetaminophen, the most widely used nonprescription analgesic, was responsible for 39% of 308 cases of acute liver failure.

Most cases of liver toxicity from acetaminophen reported by the Acute Liver Failure Study Group, a consortium of 17 centers specializing in liver diseases, were accidental and not suicides. Seventy-nine percent of them were women. "We don't know if this is because women take more acetaminophen-containing drugs than men do, if women's livers are more vulnerable, or if it's because they are smaller," says Dr. William M. Lee, the principal investigator and professor of internal medicine at the University of Texas Southwestern Medical Center in Dallas.

"We were surprised to find that the number of people with liver damage from acetaminophen was three times that of all other prescription drugs," Lee says. He cautions people to be careful of how much they take and read the labels of all over-the-counter products taken together. Mixing acetaminophen-containing medicines for cough, sleep and pain can add up to a dangerous dose. Most people in this study had taken more than 4,000 milligrams of the drug. The study of cases over a 41-month period was reported in the Dec. 17 Annals of Internal Medicine.

Herein lies the problem. Acetaminophen comes in many over the counter remedies. When one takes several remedies, one can take in excess amounts of acetaminophen. While this is unusual when looking from a population viewpoint, it seems common when looking from an acute liver injury viewpoint. This is a preventable disease, we need to educate the public better.

I am a subscriber and intellectual supporter of the Medical Letter. This publication provides unbiased reviews of drugs; it is nonprofit; it accepts no advertisements. They have introduced a new product - Treatment Guidelines - which looks very interesting. I have printed out the free sample which gives Treatment Guidelines for Diabetes Drugs. Having spent some time reviewing the 6 page guideline, I am very impressed. The guideline is well referenced and practical. I recomment that you go to The Medical Letter and click on the free issue offer under the Treatment Guideline side of the page. I am planning on subscribing.

I am quoting this entire poem from the Canadian Medical Association Journal. Here is the original link - Super-cef . It is just too good not to share.

I am Jeff. Jeff-the-Rep. Would you like some Super-cef? No, no, Jeff-the-Rep. I do not want your Super-cef. I have no time for you today. I must see patients -- go away.

Would you, could you for a pen? Monogrammed for you, my friend? You really must try Super-cef. It treats mono, it treats strep.

I would not, could not for a pen. Not for five, not for ten. Now let me be, I'm way behind. Mrs. Brown has chest pain -- do you mind?

A fridge magnet? A free dinner? This abstract says our drug's a winner. Remember while you eat these donuts Super-cef treats Pseudomonas.

Not for magnets on my fridge. I don't want your useless kitsch. My sample cupboard's overflowing. Thanks for coming -- now get going. I really must see Mrs. Brown. She just stopped breathing and fell down.

How 'bout I send you for a cruise If some Super-cef you'll use? If you sit and listen to me, I'll credit you for CME. We reps work hard -- please don't revile us. And did I mention West Nile virus?

Not for a cruise, nor CME. I have the hours I need, you see. Now Jeff-the-Rep, please stand aside. Mrs. Brown just up and died. I wish I could zap her heart. Too bad I sold off my crashcart.

You do not like my drug, you say. Try it, try it, and you may. With just one dose of Super-cef You can even reverse death.You make think Mrs. Brown is done Here, rub a little on her tongue.

Jeff-the-Rep, I've naught to lose, A last resort your drug I'll use. She's so dead it won't annoy her. Now where's that number for my lawyer? Say, look Jeff, she took a breath. I think I like your Super-cef. Although the point may now be moot Your drug has saved me a lawsuit. And I will use it for all ills From impotence to sweats and chills. And I will take a dozen pens. For rudeness I'll make amends. Donuts, dinners, CME, What else can you give to me? And I will go on the sea cruise As long as you throw in free booze. I'll tell my friends about Super-cef. Now go bug them, Jeff-the-Rep.

Study: Some Defibrillators May Be Riskier : More Sophisticated Heart Defibrillators May Have Increased Risks, Study Suggests

But most patients who need defibrillators are likely only to need less sophisticated devices equipped with a backup pacemaker, the research suggests. The backup pacemaker stimulates the lower heart chamber when the beat becomes too slow.
The researchers found increased risks with newer models featuring pacemakers that supply electrical impulses to the upper and lower heart chambers.
The newer, dual-chamber devices can be programmed to continuously regulate the heartbeat even though most people who get them don't need that much help, said researcher Dr. Bruce Wilkoff of the Cleveland Clinic.

Many doctors assumed the extra help would be beneficial for defibrillator patients, since previous research showed that stand-alone dual-chamber pacemakers helped other heart patients do better, Wilkoff said Thursday.

But in the study, within one year of getting the implants, 26.7 percent of the dual-chamber patients died or were hospitalized with heart failure, compared with 16.1 percent of patients who got only backup pacemaking help.

The researchers halted the study early because of the poor results, which could translate into thousands of hospitalizations or deaths worldwide each year.

"Bigger is not always better; more sophisticated is not always an improvement," Wilkoff said.

And kudos for doing the study and not assuming that more sophisticated was an improvment. We generally need studies because conventional wisdom does not always work.

Thyroid problems 'missed by doctors'. This article, unfortunately, relies heavily on anecdote, but does not provide any data. I choose to link though to remind myself and readers that both hyperthyroidism and hypothyroidism present with non-specific complaints.

Eye problems, rapid weight loss and being unable to sit still are all symptoms of an over-active thyroid.

Feeling run down, weight-gain and brittle hair and nails can be signs of an under-active thyroid. Both can be treated.

I have never understood why insurance companies do not pay for contraception. One could easily expect the expense to save the companies money. The introduction of Viagra (and many insurers pay for Viagra) focused attention on this issue. Apparently some states are intervening. Some states now requiring contraceptive coverage

We have spent more time discussing the smallpox vaccine, and not enough time getting educated about the disease. A prerelease NEJM article shows that the public (and probably many physicians) do not know the facts. This article provides a nice summary - With New Threat of Smallpox, a Reeducation. Take the 2-3 minutes to read this well done question and answer session.

The Washington Post today has a very nice overview of Dr. Frist - The Doctor as Dealmaker?

I am hopeful that he will bring a focus on health care issues that will help improve health care and delivery. We will all watch his performance carefully.

I have written about this issue extensively. Medicare payments to physicians are a crisis. I hope the new Senate Majority Leader understands that this is his first health care priority! Medicare to Cut Payments to Doctors 4.4%

The Bush administration announced today that Medicare payments to doctors would be cut 4.4 percent next year, after a 5.4 percent cut this year. Federal officials predicted that doctors would, as a result, be less willing to accept new Medicare patients.

If the cuts are not reversed, Congress and the administration will face the wrath of two politically potent constituencies, elderly voters and doctors who care for the elderly. But administration officials are desperately trying to control federal health costs, which they see as a major factor that contributes to federal budget deficits.

Doctors, outraged at the cuts, faulted both Congress and the administration for failing to avert the cuts, which start on March 1.

...

Doctors said the existing payment rates were already too low to cover the costs of caring for the elderly.

"Physicians cannot afford to treat Medicare patients" under the new rates, said Dr. James C. Martin, president of the American Academy of Family Physicians.

Thomas A. Scully, administrator of the federal Centers for Medicare and Medicaid Services, said he was making the cuts reluctantly.

"The reduction in physician fee schedule rates results from a formula specified in the Medicare law, and we believe that formula is flawed and must be fixed," Mr. Scully said. "Although Congress considered several options for fixing the fee schedule formula for 2003, and the House actually passed a bill to address these issues, no final action was taken before Congress adjourned."

The administration announced the cuts in issuing the Medicare doctors' fee schedule for 2003. It specifies the amounts paid to doctors for more than 7,000 services and procedures from routine office visits to complex surgical procedures.

Next year, Medicare is widely expected to pay $45 billion to more than 750,000 doctors and other practitioners.

Mr. Scully said that if the formula accurately reflected doctors' costs, they would receive a 1.6 percent increase next year, rather than a 4.4 percent cut. Congress should "fix the formula," he said.

...

John C. Rother, policy director of AARP, said the cuts in Medicare payments to doctors were "an unintended consequence" of the payment formula.

"Congress should correct it as soon as possible," Mr. Rother said. "We are getting complaints that it's becoming difficult for Medicare beneficiaries to find a doctor willing to accept them in some parts of the country. We don't want that problem to spread."

Under the formula for paying doctors, spending increases with Medicare enrollment and economic growth, among other factors. Doctors say they have been shortchanged for several years because the government underestimated economic growth in the late 1990's and the number of people who would be in the Medicare fee-for-service program.

I have several reflections on this issue. First, physicians well understand the problem of unintended consequences. Side effects are unintended consequences. Patients suffer just as much from unintended consequences as they do from disease. We get sued over unintended consequences. In my opinion, unintended consequences is not an excuse for Congress. When we have an unintended consequence, we MUST treat it. That is my prescription for Congress. Fix it, do not make excuses. When they throw their hands in the air and state unintended consequences that does not remove their responsibitily and culpability. As I learned in medical decision making research, the decision to not do something is in fact a decision. By not correcting this unintended consequence, the Senate has implicitly endorsed the decreased reimbursement.

Second, who really suffers from the decreased pyaments? I will submit that patients will suffer the most. Finding a physician will become even more difficult as more physicians stop accepting new Medicare patients, and some even stop seeing Medicare entirely. The supply of generalists is decreasing and the demand from patients is increasing. The policy director of AARP understands it (read his quote above). We will see an increase in inappropriate emergency room visits (they always increase when access decreases). We know that patients without a primary care physician tend to have worse outcomes.

Third, this debacle strengthens my fear over federal funded universal health care. While I am not a fan of our current system, I fear governmental control even more. We have a clear example here of politics hindering a clear decision. One can look at Canada and Great Britain for ongoing examples of the problems of governmental control. Thus, while I would like to see universal healthcare, I cannot understand how we could rationally implement the program. I fear the unintended consequences.

To reiterate, physicians must address unintended consequences every day. When will the Congress address this unintended consequence.

It appears that Trent Lott is stepping down and Dr. Frist will become majority leader - Lott Steps Down as Senate Republican Leader . I believe this is a very important move for medicine. Frist has championed many important causes - Medicare reform, malpractice reform, etc. Being majority leader, he will more likely have the Senate address these important issues sooner rather than later. I will try to watch his interviews and read commentaries which relate to this hope.

The Lancet has prereleased an important article - Combination treatment of angiotensin-II receptor blocker and angiotensin-converting-enzyme inhibitor in non-diabetic renal disease (COOPERATE): a randomised controlled trial. This study shows that the combination of an ACE inhibitor and an ARB does a better job of delaying end stage renal disease than either alone.

They randomized 336 eligible patients in this Japanese study. The average serum creatinine on entry was 186 microMol/L (approximately 2 mg/L). This study includes patients with glomerular disease (65%), hypertension (17%), PCKD (5%) and unknown (13%). Patients received either losartan or trandolapril or both. At 36 months only 11% of the patients receiving the combination had reached end stage, as opposed to 23% in the single drug groups. Using complex mathematical techniques, they found the following risk factors for reaching end stage - combination therapy protected, increasing age made end stage more likley, baseline renal function (the higher the initial creatinine the more likely end stage occured), the urinary protein response and a benefit from diuretic use.

It appears that this benefit of combination therapy correlates with a greater decrease in urinary protein excretion. Previous studies had taught us that the level of proteinuria predicts the progression rate. Thus, the affirmation that dual RAS blockade decreases proteinuria and retards progression rate fits with our understanding of renal disease progression.

Many nephrologists have already adopted this management philosophy. This study supports combination therapy, and also supports that generalists work with nephrologists soon after diagnosing renal insufficiency. In 2002 we should do our best to retard the progression of renal disease. This will take at least 2 drugs, and - the authors speculate - maybe more. Given the morbidity and mortality associated with end stage renal disease, our efforts are likely worthwhile.

I could not find any mention of the protective effects of diuretics (clearly topical in lieu of the ALLHAT study). I will speculate that patients also taking a diuretic probably had better BP control. Since BP control decreases the rate of progression, that could make a difference.

In keeping with my philosophy, I am urging readers to read opposing opinions on two recent issues. Medpundit is not as critical of ALLHAT is I have been, she writes about the study on December 19th (link not working). She also disagrees with my current philosophy on smallpox vaccination - and states her case well (I still respectfully disagree) - December 20th.

The FDA stands tall. FDA cracks down on bogus health claims. The FDA will no longer 'allow' health claims for foods or 'supplements' to make unsubstantiate health claims. Good for the FDA.

Today's NEJM has an excellent Sounding Board on the dietary supplement industry (subscription required) Botanical Medicines — The Need for New Regulations I will quote from the conclusions.

The medical community has been slow to respond to the public health issues and educational problems resulting from the weakened regulation of dietary supplements. However, the numerous reports of adverse effects and deaths associated with botanical health products, the distribution and widespread sale of adulterated products, and the marked increase in misleading promotional claims on the Internet demand prompt action to protect the public health. The European Parliament is currently considering measures to ensure that all traditional herbal medicinal products used in member countries have demonstrated efficacy and an acceptable level of safety. The legislative reforms we propose here are likely to be opposed by powerful political and economic forces and by many proponents of complementary and alternative medicine. For this reason, vigorous and concerted action is needed to educate the public and Congress about the critical need for new regulatory safeguards and for the government funding to implement them.

I am pleased that physicians are leading the fight in this battle. The battle is important for the public health.

I generally avoid the smallpox debate, however, I did make my opinion known earlier this year - Another caution on widespread smallpox vaccination (among a few rants). Medpundit and Bloviator (look to the left hand column) have written extensively on this issue. Today I must return to the debate.

2 Hospitals Refuse Call To Vaccinate Workers

Officials at Grady Memorial Hospital in Atlanta and Virginia Commonwealth University in Richmond said yesterday that the risk of dangerous side effects of the vaccine and inadvertent transmission to patients outweigh the remote threat of an attack with a virus that has not been seen since the 1970s. Three other large medical centers, Children's Hospital of Philadelphia, Emory Medical Center in Atlanta and the University of Iowa Hospitals and Clinics are leaning against inoculating their staffs.

The hospitals' decisions mark the first high-profile opposition from the medical community to a plan Bush announced Friday to inoculate as many as 11 million Americans by late summer and underscores some health workers' reluctance to return to a decades-old vaccine known for its serious side effects. In rare instances, the vaccine has caused life-threatening cases of encephalitis and some deaths.

"I don't like to cause disease," said Carlos del Rio, Grady Memorial's chief of medicine, describing his fear that a hospital worker could accidentally spread live vaccinia to a patient with a weakened immune system. "If, say, a patient with AIDS became infected, that would be a disaster."

Julie Gerberding, director of the Centers for Disease Control and Prevention, said she was neither surprised nor disappointed that a handful of hospitals is opting out of the program.

...

Many physicians, noting that they are in the business of risk-benefit assessment, said the Bush administration has not made a compelling case for waging a high-stakes battle against a disease that was eradicated worldwide by 1980. The only known stocks of smallpox virus are kept in government labs in Moscow and Atlanta, although some security experts fear other nations, including Iraq, may have the virus.

"There is a lack of logic to the current proposal," said Richard Wenzel, chairman of the department of internal medicine at Virginia Commonwealth. "If our government in all its intelligence thinks smallpox exists in enemy hands, why would we creep up on that policy? We would rush to vaccinate everybody right now."

I do not plan to take the vaccine unless the government were to 'force' me (I am a part time VA employee). I know Dick Wenzel, and he knows infectious disease/ epidemiology as well as anyone.

We cannot estimate the risk of a smallpox epidemic, however we do know the risk of the vaccine. We know that the vaccine works as long as 4 days after exposure to an index case. So these physicians have made the decision to follow Hippocrates recommendation - As to diseases, make a habit of two things -- to help, or at least to do no harm. (written by Hippocrates in Epidemics, Bk. I, Sect. XI (tr. by W.H.S. Jones)).

The Washington Post has entered the discussion with a poorly thought out editorial - Doctors' Orders

Doctors who administer teaching hospitals, on the other hand, have a different sort of responsibility to the community. Their job is not to assess intelligence risks or to second-guess state public health officials but to be prepared to care for sick people, and to vaccinate healthy people, in case an outbreak should occur. Clearly, health care workers are also among those most likely to be infected, particularly in the early stages of an epidemic, because they might come into contact with sick people before the disease is identified. Without a core group of immune health workers, it will be hard to respond at all to a mass outbreak of the disease. At the least, hospital administrators owe it to their own personnel to make the vaccine available, and to explain the risks of receiving it or refusing it, before dismissing the validity of the vaccination campaign out of hand.

The Post criticizes the teaching hospitals for not understanding the intelligence community and why Bush recommended the vaccine. I disagree. They imagine 'a mass outbreak' of the disease. The teaching hospitals (both well known to me) and their leaders do not believe that smallpox would present as a mass outbreak. Nor do I. I hope we do not have any significant side effects among the health care workers who do take the vaccine. I hope no one spreads even attentuated vaccinia to a susceptible patient. I believe these two hospitals have weighed the risks and benefits and found that the risks outweigh the benefits (from their vantage point). I agree.

I just added a new medical blog which I discovered today - Alex Chernavsky. Quoting him, his blog topics:

Blog subjects:

* Pseudoscience in the mental-health industry
* Unethical behavior among pharmaceutical companies
* General topics in skepticism
* Whatever else strikes my fancy

Read and enjoy!

Let us give three cheers to the American Cancer Society - hip hip hooray - hip hip hooray - hip hip hooray! They have revised their guidelines for cervical cancer screening. The new guidelines follow very nicely from the evidence. I will quote liberally from the referenced review (NY Times) because this information is so important. Less Screening Urged for Some for Cervix Cancer. For those who want the source document - American Cancer Society Guideline for the Early Detection of Cervical Neoplasia and Cancer

Among those who do not need Pap tests, the cancer society says, are women who have never had sexual intercourse, women who have had total hysterectomies that included removal of the cervix for reasons other than cancer and women age 70 or older who have had three or more normal Pap test results and no abnormal results in the last 10 years.

While I might quibble with the age (data suggest that 65 is also a reasonable cut off) the concept makes sense. I never could understand why we would try to do a Pap smear on a woman who had no uterus (since the Pap was looking for cervical cancer and the cervix was gone). Nice to know that my logic was not totally flawed.

"You don't want to screen a virgin, but is the woman either not telling, or can't tell?" said Dr. Debbie Saslow, director for breast and gynecologic cancer at the cancer society.

For that reason, the guidelines state that cervical cancer screening should begin about three years after a woman begins having vaginal intercourse, but no later than age 21 if there is any question about the truth.

Then, screening should be done every year with standard Pap tests, or every two years if the doctor uses a newer, more accurate type of Pap test in which the cells scraped from the cervix are suspended in liquid instead of being rubbed directly onto a microscope slide.

At or after age 30, women who have had three normal tests in a row no longer have to be tested every year. They can be screened every two or three years, though more frequent tests may be recommended for women with H.I.V. infection or certain other health problems.

Dr. Saslow said, however, that even a woman who does not need yearly Pap tests will have to see a doctor at least once a year for matters like birth control, sexually transmitted diseases and problems arising from menopause.

The new guidelines, published in the November-December issue of the cancer society's journal CA, were developed to help reduce the number of women who are screened needlessly and get falsely positive or ambiguous results that lead to costly, unneeded and nerve-racking invasive procedures. About 50 million women a year in the United States have Pap tests.

These guidelines should greatly decrease the number of Pap tests without putting woman at significant danger. The NY Times article does not discuss HPV testing. In combination with the new liquid based tests allow a 2 step procedure with HPV testing following the finding of ASCUS. Those with a positive HPV will need culposcopy, those who are negative will need careful followup. I found this paragraph from the guidelines worth considering -

Screening interval remains a controversial issue in the United States. While the evidence supports the conclusion that conventional cytology can be safely performed at two- to three-year intervals, many women and providers in the United States may be more comfortable with annual screening. A key factor is the limited sensitivity of the conventional Pap test. A significant proportion of false-negative conventional cytology results are due to inadequate sampling; improvements in the ability to obtain an adequate sample would increase the sensitivity and effectiveness of conventional cytology. In addition, many experts believe that the use of new technologies such as liquid-based Pap tests and HPV DNA testing (in combination with cytology), when performed at a less frequent interval, offers several advantages over conventional cytology smears alone. These advantages may include increased sensitivity, lower long-term costs, and facilitation of the triage of ASC-US results. If used at the same interval though (e.g., annual LBP compared to annual convention cytology), new technologies would significantly increase the number of women referred for colposcopy unnecessarily, greatly increasing health care costs and harms to patients, with little or no benefit.

It is important to reiterate that the biggest gain in reducing cervical cancer incidence and mortality would be achieved by increasing screening rates among women who have not been screened or who have not been screened regularly. Missed opportunities for screening abound, particularly among unscreened older women, women of low income and/or low education, and women who are uninsured or underinsured. Clinicians, hospitals, health plans, and public health officials should seek to identify and screen these women, and to ensure continued screening at regular intervals.

As a member of the Society for Medical Decision Making, I am very pleased that the American Cancer Society has carefully studied this screening question. They clearly have tried to balance the questions of sensitivity and specificty. The new guidelines consider the costs of false positive tests explicitly. They have worked to balance the benefits of true positives (and limiting false negatives) with the costs of false positives. Once again kudos to the ACS for this major advance!

When a huge study like ALLHAT is released, I find that I need to read, and think, and then think some more. This morning I would like to go through the study in a bit more detail.

Trained observers using standardized techniques measured BPs during the trial. Visit BP was the average of 2 seated measurements. Goal BP in each randomized group was less than 140/90 mm Hg achieved by titrating the assigned study drug (step 1) and adding open-label agents (step 2 or 3) when necessary. The choice of step 2 drugs (atenolol, clonidine, or reserpine) was at the physician's discretion. Nonpharmacologic approaches to treatment of hypertension were recommended according to national guidelines. Step 1 drugs were encapsulated and identical in appearance so that the identity of each agent was double-masked at each dosage level. Dosages were 12.5, 12.5 (sham titration), and 25 mg/d for chlorthalidone; 2.5, 5, and 10 mg/d for amlodipine; and 10, 20, and 40 mg/d for lisinopril. Doses of study-supplied open-label step 2 drugs were 25 to 100 mg/d of atenolol; 0.05 to 0.2 mg/d of reserpine; or 0.1 to 0.3 mg twice a day of clonidine; step 3 was 25 to 100 mg twice a day of hydralazine. Other drugs, including low doses of open-label step 1 drug classes, were permitted if clinically indicated.

Remember that the doxazasin arm ended previously because of worse outcomes. So reading the methods above we understand that the comparison in most patients is of chlorthalidone in combination with atenolol, reserpine or clonidine versus lisinopril in combination with those drugs versus amlodipine in combination with those drugs. Over 40% of the patients needed a second drug to achieve the goal BP.

I argued yesterday (and apparently I am not alone) that this study markedly disadvantaged ACE inhibitors by providing a second drug which is not complementary. I almost always add a diuretic to the regimen when starting with an ACE inhibitor. If I have started with a diuretic, I then generally add a beta blocker or an ACE inhibitor. This study did not test how I practice!

The NY Times has standard coverage today. They do seem to miss the coming debate over the study. Older Way to Treat Hypertension Found Best and Diuretics' Value Drowned Out by Trumpeting of Newer Drugs. I recommend theheart.org (one cannot link to articles there) as a site which gives a very balanced review of the pros and cons of this study.

So what do I do now? I do not think that I change my style. I have used low dose hctz for simple hypertension or ACE inhibitors if there are other clear indications for their probable benefit. When I need a second drug, I generally use a combination of the two. When money is a concern, I use generic captopril (very cheap, much cheaper than the news reports suggest) which one can use b.i.d. for hypertension. I have tried to avoid calcium channel blockers for several years now, and will continue that philosophy.

Theheart.org has an excellent review of the ALLHAT trial with solid critiques. I will include this important quote from the Steering Committee Chairperson

Furberg acknowledged that the order of add-on therapies probably disadvantaged the ACE inhibitor in this trial, noting that in "real life" patients on ACE inhibitors would receive diuretics, not beta blockers.

"The complicating issue with the interpretation of ALLHAT is that we didn't get the same blood pressure reduction with the ACE inhibitor, and so if the ACE inhibitors come out a little bit behind, we don't know if that is because of an ACE inhibitor effect or that we didn't get the same blood pressure reduction, and that applies primarily to African Americans," he said. Because blood pressure reduction was similar with the diuretic and the CCB, the superiority of the diuretic in that comparison is clear, he said, but more information from studies other than ALLHAT will be required to get a clearer answer on the ACE inhibitors, particularly in African American populations.

But, he adds, "ACE inhibitors have proven effects in a lot of other patient groupsheart failure, postinfarction, and so onand so particularly in patients with comorbidity, I think they should be considered."

Exactly the point that I made earlier today. I stand by my former post!!

The Neolibertarian New Portal scooped me!! Older, Cheaper Drugs Are Better For High Blood Pressure. I must take some exception to the title. I have quickly browsed the article - Major Outcomes in High-Risk Hypertensive Patients Randomized to Angiotensin-Converting Enzyme Inhibitor or Calcium Channel Blocker vs Diuretic :
The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) - and the results are much more complicated than any new report will summarize.

The diuretic treated patients had slightly, but significantly better BP control. The protocol did not include adding a diuretic to patients receiving the ACE inhibitor - rather a different second line therapy. I would argue that the protocol does not represent current practice. While I generally favor starting with an ACE inihibitor, I then choose a thiazide diuretic as the second line drug.

The article includes massive amounts of data. They did not find any mortality differences.

So will this change my practice? Probably not! I will still start with an ACE inhibitor and generally add a diuretic as the second drug. It will take several weeks to absorb all the information in this study. I will continue to avoid calcium channel blockers. I will work diligently to achieve excellent BP control.

Surprise! Surprise! Surprise! Study Skeptical on Echinacea's Benefits. First, what a lame headline. Read this paragraph and then what headline would you write.

Echinacea, a popular but largely untested herbal remedy for the common cold, showed no benefit when given to a small group of college students with sore throats and stuffy noses, researchers say.

University of Wisconsin researchers gave capsules of the herb to 73 students suffering from cold symptoms. Another 75 got a placebo, or dummy pill, made of alfalfa. After 10 days, both had gotten equally ill, the study said.

``Compared with placebo, unrefined echinacea provided no detectable benefit or harm,'' researchers wrote in the study published in Tuesday's edition of the Annals of Internal Medicine.

Herbal remedies are mostly a bunch of hooey (hooey - n : senseless talk; "don't give me that stuff"). The consumer has no idea what they are actually buying as there are no quality control standards. Why do we tolerate this bogus industry? Why do we glorify it with a high falutin' name like 'complementary or alternative medicine'? I call it what it is - quakery. We waste money on this garbage, sometimes even putting our health at risk. And soon I will tell you how I really feel!!!

Chronic sinusitis frustrates patients and their physicians. Recent experience shows that generally surgery is not the answer. Is sinusitis an immunologic response to something? And is that something fungi? Doctors Rethinking Treatments for Sick Sinuses

Researchers at the Mayo Clinic achieved a breakthrough in 1999, when they found that some inflammation was caused by an immune response to fungi in the nose. Patients and control subjects had many different species of fungi in the nose. But just those with chronic sinusitis have white blood cells, known as eosinophils, that are activated by the immune system, the researchers found.

Led by Dr. Jens Ponikau, they discovered that the immune system sends eosinophils to attack fungi. The eosinophils release a protein that irritates the membranes in the nose. The irritation remains as long as the fungi are present.

A paper on their findings will be published in a peer-reviewed journal next month.

The Mayo team is treating patients with antifungal solutions. Clinical trials are continuing, and patients who have been treated have given encouraging reports. "But we have to settle in for the long haul," Dr. Ponikau said. "It's a paradigm shift, a different way of looking at the disease."

Some doctors have succeeded with a class of asthma drug called leukotriene receptor antagonists. They works by blocking leukotrienes, substances that the immune system secretes in asthma and allergy attacks and that inflame the respiratory tract. Patients with sinus disease often have asthma, as well.

"Asthma patients who used these drugs found that their sinus symptoms were eased,," said Dr. Michael Setzen, who has a practice in Manhasset, N.Y., and is an assistant clinical professor of otolaryngology at the New York University School of Medicine. "If it works, patients know it right away."

An asthma medication, Singulair, the trade name for montelukast, is awaiting approval from the Food and Drug Administration for allergy symptoms. Many doctors, however, prescribe it for sinus problems.

Many years ago, my father, a clinical psychologist, started to espouse the stress reaction as a major risk factor for disease. Obviously he was not alone. I highly recommend reading this long NY Times article on stress. The problem is clear, the solutions elusive - The Heavy Cost of Chronic Stress

If you read yesterday's post, and want to read further, please read Syndey Smith's comment (she of Medpundit). Also check out this complimentary explication from RangelMD - Generalists and Specialists. I love the collegial atmosphere of the blogosphere!

It does not matter whether I am brilliant as a physician if the patient does not receive good nursing care. Others have documented the nursing shortage, and we have all wondered what the problem is. As usual, it is about money, but not the money that nurses make (that is pretty darn good at this time). The problem is the low pay for nursing instructors and therefore (we do not need an economist to figure this one out) a relative shortage of instructors. Nursing Students Overwhelm Schools

There's a nationwide shortage of nurses, as anyone who's spent time in a hospital lately knows. And by 2020 that shortage is expected to grow to more than 800,000 nurses nationwide, according to projections by the U.S. Department of Health and Human Services.

But the problem isn't finding people who want to be nurses, it's getting them into nursing schools.

Rasmussen was rejected twice from nursing school -- one of thousands of qualified people turned away from the profession each year because nursing colleges lack space, faculty and funding.

``It was so frustrating,'' said Rasmussen, who was finally accepted into Washington State University's Yakima nursing program. She has a job waiting for her in a hospital maternity ward when she graduates in May.

U.S. nursing schools turned away nearly 6,000 qualified applicants last year, according to a survey by the American Association of Colleges of Nursing.

``Some of them will reapply. Some of them go to other schools, community colleges and private schools. A significant pool will be lost to nursing,'' said Washington State University College of Nursing Dean Dorothy Detlor, whose program rejects two-thirds of its qualified applicants each year. ``It's a serious problem across the country.''

A new federal law, the Nursing Reinvestment Act, expands scholarships for student nurses, offers grants for nursing schools and includes loan forgiveness programs for nurses who earn advanced degrees and become teachers.

Nursing educators applaud the law, but are waiting to see if Congress puts money behind it. The House Appropriations Committee will determine funding next year.

Someone in the government needs to pay attention to this.

Medicine has an ongoing tension. What is the value of the generalist; what is the value of the specialist? How do we balance their skills? Which patients need a specialist? When can the generalist provide the best care?

I find this an interesting debate (albeit an implicit one). The pendulum swung in the early 90s towards 'primary care'. Specialists apparently felt threatened. They began to publish studies which showed that they could provide better care for their particular condition than could a geneeralist.

I find these results interesting but uninformative. These studies, e.g. do cardiologists specializing in heart failure do a better job of caring for heart failure than generalists, or do rheumatologists do a 'better' job of caring for rheumatoid arthritis, are asking the wrong question! We are taught early in medical school that the 'unit of importance' is the patient, not the disease. Good physicians care for patients, not diseases.

So what is the value of the generalist? The generalist should excel in diagnosing and managing the 'undifferentiated' patient. When the patient comes to the office or hospital with complaints (rather than after being diagnosed with a specific disease), the generalist should be able to consider the breadth of the complaints, physical findings and laboratory data to lead to the diagnoses. Generalists should have open minds, considering all possibilities. Unfortunately, when the only tool a carpenter owns is a hammer, everything looks like a nail. Many specialists view the world through specialty colored glasses.

Generalists tend to excel in prevention. We are more comfortable with appropriate uncertainty. We understand time as a diagnostic test and therapeutic option.

Specialists excel in various aspects of medicine. Many specialities have associated diagnostic and therapeutic procedures. They often can help with either the unusual diagnosis (e.g., a patient with new restrictive lung disease) or an unusual presentation of a common disease. Specialists become more comfortable treating the less common disease of their specialty, e.g. Crohn's disease, SLE, or using complex treatments like interferon and ribavirin for hepatitis C. Many specialists excel in caring for a specific chronic disease.

The challenge in medicine is to find the best physician for the patient. I would argue that we need more specialoids. What is a specialoid? When a generalists cares for large numbers of a disease, they become a specialoid. Many generalists are specialoids in HIV care. The key to being a specialoid is volume and interest (manifested by extra reading and perhaps conferences). One could become a diabetes specialoid.

Now the crux of my argument. Once the patient has several problems, a generalist should provide better care for the patient. Having one physician who can balance the diseases and their treatments must be superior to having 3 or more specialists each caring for a separate organ system. None of us really wants care by committee.

Even with one chronic disease, I would argue that a specialoid (a generalist with a special interest which does not dominate their entire practice) will do a better job on the problems not related to the chronic disease. I woud refer you to the following editorials from Clinical Cardiology - Cardiovascular Diabetology and Cardiovascular Diabetology - Two Years Later. Let me quote from the original editorial -

Cardiologists know a little bit about endocrine diseases and endocrinologists know a little bit about cardiovascular medicine. Diabetes may be the disease that allows both disciplines to develop a combined strategy to prevent or modify the serious complications of this disease.
Epidemiologic studies from Framingham have long ago shown that diabetes mellitus is a potent independent risk factor for cardiovascular disease.
Of all patients with diabetes, approximately 80% die of cardiovascular disease. Diabetes can affect the heart in many ways, including premature and extensive coronary artery disease, neuropathies, cardiomyopathy, and disease of the microcirculation. Two excellent review articles, one by Butler et al. and one by O'Keefe et al.,provide the reader with a solid background for understanding the complicated nature of diabetes mellitus and its relationship to cardiovascular disease.

...

Endocrinologists (diabetologists) need to educate the cardiologist, and vice versa, if we wish to optimize therapy of the diabetic patient with cardiovascular disease. Joint conferences would be a good start.

In my world, the patient with coronary artery disease and diabetes (who probably also is hyperlipidemic and hypertensive) needs a generalist. That patient needs comprehensive care, not fragmented care. What if the patient develops depression? Who will remember to screen for colon cancer?

The world needs specialists. I consult them and value their advice and help. The world also needs generalists. We must understand the value each brings to the health care table. Insurers should understand the skill and time involved in caring for these complex patients. Researchers should ask the question, how can we best care for the complex patient? I believe this is the true role of the well trained generalist.

I always include good fitness articles. As readers know, I have become a zealot on both cardiovascular fitness and resistance training. Some physicians have wondered about the risk and benefits of running. Could the jogging cause osteoarthritis? Does it have other adverse effects? (I suspect those physicians fit more into the couch potato mold). Jogging is back in the running

JOGGING HAS BEEN THE SUBJECT of many medical scare stories in recent years. It has been blamed for everything from sagging breasts to premature wrinkles and damaged joints, and has even been cited as a fast route to a heart attack.

So it is astonishing to learn that some experts are now suggesting that if you make one concession to the post-festive fitness frenzy, it should be to take up running.

Not only is jogging considered good for us because it whittles away fat cells, but it is thought to be helpful in protecting — yes, protecting — our joints. Scientists at Stanford University in California have recently carried out research which suggests that regular running can delay the onset of arthritis by 12 years.

Professor Jim Fries, an expert in healthy ageing, and his colleagues at Stanford’s school of medicine followed 538 runners and 423 couch potatoes for 17 years. They found that only 5 per cent of the joggers experienced osteoarthritic pain during that time, compared with 20 per cent of the sedentary group.

...

Injuries are more often caused by the shoes a jogger wears than by the action of running. “Most of the injuries I treat are caused by people wearing worn-out or unsuitable running shoes,” says Trevor Prior, a leading podiatric surgeon who treats many top athletes and football players, and works for UK Sport (formerly the Sports Council).

“Trainers have a shelf life of 300 to 500 miles,” Prior says, “after which they lose their support and cushioning and need to be thrown away. You should make sure that you visit a specialist shop when you buy a new pair, as requirements differ. It is natural for most people’s feet to roll inwards (or pronate) when they run, but some shoes don’t compensate for this. If you wear trainers that cause you to over-pronate, you may be at risk of backache, hip pain and knee problems.”

Let me emphasize this point. I started a serious cardiovascular fitness program 3 years ago (when I lost around 30 pounds). For around 6 months I was doing fine, then I developed knee and foot pains. At the time, I was very unsophisticated about shoes, but a friend recommended that I go the a running shoe store. Lo and behold, buying the right shoes greatly helped.

I still had knee pain though. Many runners and most trainers know that runners often develop relative atrophy of the vastus medialis . When this occurs one can develop the patello-femoral syndrome . Shoes helped greatly, but until I started strengthening my quadriceps I still had pain after running.

So what is the moral of my ranting? First, do cardiovascular exercise regularly. Second, invest in a good pair of shoes which fit your foot pattern. Third, if you choose running, do some resistance training, especially focusing on you legs. Your heart, bones and joints will all benefit.

Hospitals Trimming Treatments for Dying

Time after time, Peter Clark heard parents at Georgetown University Hospital beg doctors to save the lives of their dying children.

And throughout the neonatal intensive care unit, he heard doctors promise to try. Even if it meant cramming tubes down the children's throats, cutting open their chests or bombarding their frail bodies with radiation. Even when they knew the treatments couldn't save them, and would only fill their final days with pain.

"Some of the parents were waiting for a miracle. How do you deal with that?" said Clark, a Jesuit priest and professor at Saint Joseph's University in Philadelphia. "In some cases, you have to give the family a little more time. But where do you draw the line?"

Clark spent a year observing medical ethics at the Washington, D.C., hospital. The dilemma he witnessed occurs daily in hospitals nationwide, and a growing number have crafted policies allowing doctors to cease aggressive treatments of terminally ill patients, even when relatives want them to keep fighting.

Within a year, the Hospital of the University of Pennsylvania plans to adopt ethics guidelines under which doctors could decline to admit patients to an intensive care unit if they have been in a persistent vegetative state for at least three to six months.

In such cases, the hospital would continue to offer care to ease a patients' pain, but wouldn't take invasive steps like putting the patient on a breathing machine or performing surgery, said Dr. Horace DeLisser, who co-chairs the ethics committee implementing the guidelines.

So goes the most heart wrenching debate in medical ethics - what is futile? I have invoked futility a couple of times in the past 5 years. It is painful. It pits physicians against families. If can split the staff. Each person looks at this decision through different lenses.

Some want to use religion to justify their position. Most physicians want to limit pain and suffering - not just of the patient but also of the family.

What is futile? Is it like pornography (i.e., you know it when you see it)? How have I made that determination?

In those cases where I felt we had reached that stage, I first explored the concept with my resident and interns. If we all felt comfortable, we then consulted our hospital ethics committee. They independently assessed the patient, and in the cases I can remember, confirmed our assessment.

Interestingly, I have not dealt with futility since we have had a very active palliative care service. These wonderful physicians have greater skills with patients and families than I have. While I think that I do a very good job (I grade myself a B+ or A-), they are clearly superior (A+). They spend extensive time with the patient and family (and I can only thank the hospital administration for supporting this effort). Their approach mixes patient autonomy with strong patenalistic urging. This approach succeeds in limiting the unnecessary use of medical care in patients who clearly would not benefit.

I still expect to have occasion to consider futility in the future. Even the kindest most compassionate physician encounters families with seemingly irrational expectations. What will I do when that occurs again? I probably will try to invoke futility.

Let me assure my non-physician readers that this is not a monetary issue. My concern is over prolonged suffering for the family. I worry about the effect of these unnecessary efforts on the medical staff. Caring for a patient with no chance of meaningful recovery is very draining and demoralizing. My concerns focus on the physicians and nurses who care for these patients.

Hospitals Will Be Rated On Their Performance

The U.S. hospital industry said yesterday it will establish a system that for the first time will let consumers judge an individual hospital's performance -- and compare it directly with others' -- based on nationally recognized indicators of quality.

The system will start next summer with the unveiling of report cards on how well hospitals performed on 10 measures of good medical treatment for three common but serious conditions -- acute heart attack, congestive heart failure and pneumonia. It expects to add more diseases and measures, eventually numbering many dozens, over the next few years.

The initiative, which will be overseen by the federal government, marks the first breakthrough in a 15-year standoff between hospitals and consumer groups over how to gauge hospital performance in a meaningful way. In addition to helping patients make decisions about where to obtain care, the system will be a powerful engine pushing doctors to make their treatment decisions conform to proven "best practices."

I will take a few paragraphs to dissect this and comment. First, we must understand what the hospitals will measure. The articles mentions 2 of the 10 measures. Has a patient admitted with CHF had their cardiac function measured (I assume they would accept an echo, a MUGA or a catheterization)? Is that patient prescribed ACE inhibitors? Apparently they have 10 such measures identified for pneumonia, myocardial infarctions and CHF.

These measurements, what to measure, and how to improve quality, are the focus of much of our current research. While the announcement seems simple and straightforward, the problem has many complexities. Developing the quality measures requires careful thought. For example, I expect beta blocker use after MI to be a measure. We all agree that beta blockers are clearly indicated after MI, but we have much debate on the contraindications. Many physicians are hesistant to use beta blockers in patients with diabetes, COPD, or asthma. Others argue that cardioselective beta blockers should not cause problems in those patients. Who will construct the measures and the exceptions? How will the physicians at the hospitals receive education on these measures?

While I see some problems here, the effort is laudable. Our research (and that of many others) shows that many important medical measures are not given to patients. Our research has focused on why that occurs and how to improve physician adherence to well constructed non-controversial guidelines.

I hope that this hospital program encourages more efforts to help physicians provide better care for their patients. We need more than report cards. We need to understand how to provide the best known care to all patients. If the program is properly constructed, we can achieve that goal.

Finger-lickin' dumb

When it comes to obesity, HHS demonstrates a pattern of disingenuity. The Health and Human Services Department likes to point out, for example, that obesity has soared in the United States. Indeed, to hear Mr. Thompson, Americans are in the midst of an "obesity epidemic." This year, 31 percent of adults are deemed obese, a sharp rise from 23 percent in 1994. That's a deeply troubling statistic.

It's also highly misleading. America's stout-bodied ranks didn't swell by eight percent in as many years. Rather, in 1997 the U.S. changed its standard to conform to the stricter definition of the United Nations' World Health Organization. Literally overnight, millions of adults previously classified as slim and trim found themselves overweight.

Which is not to say that obesity isn't a serious issue. But there are a host of (mostly sad) sociological factors that contribute to Americans' unhealthy lifestyles — the overdependence on automobiles, for example, the decline of public recreation and the increase in single-parent homes. The fast-food industry sells food, period. It's up to the individual — and not the government — whether hamburgers are a smart meal choice every day.

As a physician, I believe that I see and care for more patients who are obese than who are not. Let me clarify my personal (and admittedly anecdotal) definition - BMI > 30 and not physically fit. I would guess that these patients have increased waist circumference and body fat percentage of at least 30%.

I see far too many patients with 'the metabolic syndrome'. How do I define the metabolic syndrome? Patients generally have hypertension, type II diabetes, and hyperlipidemia. They are at least overweight and usually obese. If we have not yet diagnosed their coronary artery disease, we probably will soon. And many of these patients smoke.

One way of operationalizing the importance of fast food would take a large number of these patients and compare their diets to a matched control population. The investigators could match on demographics including living circumstances (zip code, number of people in the household). Then they would do a dietary survey - how often do they frequent fast food restaurants. I would bet that many obese patients eat predominantly slow foods - that is, foods cooked at home. Certainly here in Alabama, the average diet does not need fast food joints to become 'unhealthy'.

So how do we change lifestyle? How do we add some movement to everyone's day? How do we right size portions?

As Hamlet said (you always get the best quotes from Shakespeare) - ay, there's the rub! The 'treatment' may be more difficult than the disease. Most patients enjoy their inertia. The inertia of sitting on the couch, watching TV, eating chips, and eating the same old foods is insidious. And they gain a few pounds a year. Not much each year, but they have no place to put those pounds. And the cardiologists have big houses, and the drug companies make money on ACE inhibitors and statins, and life expectancy decreases for those patients, and I pay higher insurance rates to help pay for their increased medical costs.

Today's Wall Street Journal has a column titled - Doctors Aren't Immune To Pitches by Drug Firms. If you can either get your hands on the print version or subscribe to the online version, I recommend reading the entire article. I have written previously about the dangers of getting our information on new drugs from the industry which profits by selling those drugs.

Doctors underestimate their susceptibility to the sales pitches and perks offered by drug companies, and that isn't good for patients.

The latest twist in the continuing debate focuses on promotion posing as continuing medical education. (Related article) Most physicians say they can separate selling from science, and many believe marketing is a black art that sways only lesser mortals.

Yet a growing body of academic research shows that doctors are vulnerable to drug-company influence. Add the increasing volume and sophistication of industry promotion to that predisposition, and the result should have patients wondering whether a ghost writer is at work behind their doctor's prescription pad.

"Doctors are like anybody else who is influenced and generally would deny it," observes Robert Goodman, an internist at Columbia Presbyterian Medical Center in New York and a medical school teacher.

Doctors are "smart, tend to be a little bit arrogant, and are very naive about business," explains Dr. Goodman, who founded a group called nofreelunch.org to persuade doctors to renounce drug-industry influence on their practices, teaching and research. The "more you think you're immune, the more you're willing to partake."

Most drug reps avoid me, as I am argumentative and often obnoxious when approached. When they have a good product I do praise them. I personally will not accept anything valued over $10 (yes I will eat the lunch or the cookies). I get most of my drug information from the Medical Letter and the Prescriber's Newsletter. I pay for those services and believe them unbiased.

We should not fool ourselves. The drug reps are buying influence and we should not be selling out.

Why mistakes occur in hospitals: An exhaustive study zeroes in on dangerous errors in medication. As I read this article I just nod my head. I wonder at the brilliance that many hospital administrators show when they decrease nursing and pharmacy staffing. Or when they 'downgrade' the level of nursing (e.g. RN to LPN). These errors can be extremely dangerous, and yet as a physician I can only write the order properly. Working mostly at a VA hospital, we enter our orders by computer - eliminating handwriting errors. Yet we see all these problems.

Hospital medication errors occur with alarming frequency, studies have shown, causing thousands of injuries and deaths each year. Now research has pinpointed exactly where, and how often, those mistakes occur.

United States Pharmacopeia, which establishes quality standards for medicines, announced the results last week of the most exhaustive study to date on hospital medication errors. The report said most errors involved the omission of prescribed drugs, dispensing the wrong drug, improper dosages and failure to properly administer prescribed medications. Such information is essential to devising effective strategies to prevent mistakes, said Diane D. Cousins, a USP vice president.

Claritin price to drop by as much as 76%: Allergy drug to be available over the counter this week. Hmmmmmmmmmmppppppphhhhhhhhhhhh! How can that happen? And you know they are still making a LOT of money on the product!

PHARMACISTS IN New York and New Jersey said they plan to sell the basic version of the drug for between 92 cents and $1.17 a tablet, depending on the number of pills in a package, down from as much as $3.80 a pill in its prescription form. The exact price could vary by region and from store to store.

Last month the Food and Drug Administration cleared five formulations of the drug for over-the-counter sale, including Claritin-D tablets, which also contain a decongestant. Claritin-D will sell for a little more than basic Claritin.

This is still an expensive drug, but not as outrageously expensive as it was. This dramatic price drop show us the insanity of current pharmaceutical pricing.

Statins: Miracles for Some, Menace for a Few. Read this good balanced review - you might want to print it out for patient information.

Healthcare getting greater attention .

"It is clear that healthcare will be a real priority for this administration," Grace-Marie Turner, president of the Galen Institute, told United Press International. "It is genuinely refreshing because Republicans have always been weak on these issues."

Since the election, Karl Rove, President George W. Bush's chief political adviser, and other top officials have been making the rounds of think tanks and health care advocacy groups in an attempt to garner support for a far-reaching reform agenda. At the same time, congressional leaders are reportedly gearing up for policy efforts that may be at odds with the White House plans.

...

Rove, for example, has been talking up the administration's health policy agenda, stressing the importance of making progress on the issue in the new Congress.

According to those who have attended meetings with Rove, he has outlined an agenda that focuses on medical malpractice reform, Medicare reform with the possible addition of a prescription drug benefit, and on government help for the uninsured.

According to one administration source, Rove is prioritizing policies that can help gain political capitol for Republicans in the 2004 election, but that also do not have large budgetary needs. Medical malpractice reform, for instance, is said to be a top priority of the administration precisely because it will cost little to implement.

Those who follow the issue also see the fact that the nation's trial lawyers are also major supporters of the Democratic party as a significant driving force behind Republican support for limiting damages in medical malpractice cases.

But Tom Miller, director of health policy studies at the libertarian Cato Institute, said that prospects for such a bill are limited, given the small margin of power the Republicans now hold in the Senate, which falls short of the 60 votes needed to kill a Democratic filibuster of such a measure.

Unfortunately, we must all follow the politics carefully. What happens in Congress affects our practices and our ability to provide excellent care to patients. Unfortunately, politicians are not really worried about patient care. As I have written often, the Democrats position on malpractice reform is not understandable. Nor is the Republican position on the pharmaceutical industry. Hopefully, we can get some progress this year. (I remain the eternal optimist).

I write a lot about fitness. These cardiologists 'just do it'. Dungeons and doctors: These physicians take a no-frills approach to exercise: It's cold, spartan and dank. But the garage-now-gym is the early-morning place to be for four weight-lifting cardiologists.

Three days a week, before work, Dr. Mishkel and three colleagues from St. John's Hospital come to lift weights at the Dungeon Training Center, a garage-turned-gym in Springfield, Ill. With its concrete floor, exposed wiring and insulation and duct-taped window, it seems an unlikely place for doctors to exercise.

But they love the camaraderie here, the workout routines and the physical and mental boost that pumping iron provides. Proudly, they are slaves to the dungeon.

"It's freezing in the winter and it's boiling in the summer. There are times when it's cold and I wish at 5:30 in the morning we had some heat," said Dr. Mishkel, 45. "It's not a gym that one would normally associate a bunch of physicians to be at."

From about 5 a.m. to 6:30 a.m. Monday, Wednesday and Friday, the Dungeon is where you will find Dr. Mishkel, Stephen Jennison, MD, Richard Ammar Jr., MD, and Kriegh Moulton, MD. All four work for Prairie Heart Institute at St. John's in Springfield. They range in age from 37 to 50.

The workouts offer them a way to practice what they preach. Advice about staying fit means more coming from a healthy doctor than one who's noticeably out of shape.

"It's very hard to preach to patients if you're overweight. In many ways, you can motivate patients if they see you're in reasonable shape," said Dr. Mishkel, who stands 5 feet 9 inches and weighs 170 pounds.

Dr. Ammar agrees. "Coming from a slightly pudgy cardiologist, patients are like, 'Yeah, right buddy. What about you?' "

My personal experience supports this last comment. Patients do take you more seriously when you have a desirable body habitus (at least in terms of fitness and weight loss advice). I would love to see a study comparing pudgy and fit doctors advice (and even the likelihood that they would emphasize fitness and weight loss).

What is DTC? Direct to consumer! Misled About Medicine: Government Report Says Some Drug Companies Use Deceptive Ads. We know this. What does Viagra have to do with dancing?

Last year, pharmaceutical companies spent more than $2.7 billion on advertising aimed at consumers, and the report shows that it was money well spent since patients requested and received prescriptions based upon their viewing of a specific ad.

The government says that ads with deceptive images — such as an ad for the arthritis drug Celebrex that depicts an elderly woman rowing a boat and riding a scooter — often exaggerate the benefits patients can expect from a medication.

In sum, the government report indicated that since 1997, the Food and Drug Administration has issued 88 letters to drug companies complaining of advertising violations.

"The violations have to do with companies overstating the benefits of their drugs, failing to adequately tell people about the risks and not balancing the good news with the bad news about the drug," said Dr. Sidney Wolfe of Public Citizen Health Research.

These ads give patients incorrect impressions about disease and treatments. They can negatively impact the doctor patient relationship and use valuable time to discuss the requested drug which is not indicated. I doubt that one can find many physicians who would endorse this practice.

Medicare is a pain in the butt! It comes with so many regulations that the money becomes almost irrelevant. Medicare regulatory reform panel looks to cut red tape: Work is under way to implement hundreds of recommendations to relieve the paperwork burden.

Of the 255 recommendations, more than half were directed at the Centers for Medicare & Medicaid Services. The agency has already implemented 17 of those suggestions, and agency officials said work was under way to implement scores of further reforms.

Thompson called the initiative a "great step forward, but only the first step." He pledged to continue the process of culling the reams of rules that practitioners confront in dealing with government health programs.

"Our work doesn't stop here. We will continue to carefully consider all of the recommendations and take appropriate steps to promote quality care of all Americans," Thompson said. "We will continue to focus on the potential impact that reducing regulatory burden may have on patient care as we review existing requirements and consider new regulations."

I am personally most interested in the E&M guidelines. They are not constructive and just produce ways to document high care. They make physicians documentation experts rather than reward good medical practice. They are indecipherable and uninterpretable by experts! We need a better system and I can only hope we get one.

Senate leaves Medicare pay fix undone: Congress adjourns before addressing the problems with the physician reimbursement rate. Now the new rates will be published. Congress has 60 days to change the published rate, so all is not yet lost. Secretary Thompson of HHS says this is a high priority.

I still cannot understand why the Senate would not address this issue previously. Since the House passed a bill fixing the rate problem twice, I must hope that the new Republican majority Senate will address this successfully. We must follow this issue carefully. Organized medicine has united in working for this issue.

The Healing Paradox. I hesistate to use the title alternative medicine as that gives the herbs and incantations more credit than they deserve. Given the public's fascination (and financial investment), we (physicians) need to better understand the phenomenon.

But my morning paper, laden with science, also carries evidence of our distrust of science and our search for another kind of healing. You've seen it: a full-page advertisement for a product that you know is too good to be true. The text has large type, a before-and-after picture, no listing of the contents of the product and a blizzard of endorsements from ''scientists'' and ''patients'' that take the place of data. These products are life extenders, fat fighters, growth-hormone releasers, relievers of limb pains, rebuilders of muscle and bone and sometimes all of the above together. I think of them as quark drugs, phantoms that if they could be studied in careful trials would soon lose the ''r'' for a ''c'' and be revealed for what they are.

But the market for such remedies is huge. Indeed, estimates are that nearly half of all adult Americans use some sort of dietary supplement, and the sales of these products in 2000 amounted to more than $15 billion! I plead guilty: echinacea and ginkgo have made appearances in my medicine cabinet, as I reached for magic for some ailment or other. I had no guidance, no data of the sort a scientist should accept, no package insert. I tried them on faith. Alas, they did nothing.

The author describes the phenomenon and then tries to understand. I think he probably has figured it out.

Therein lies the rub: we are perhaps in search of something more than a cure -- call it healing. If you were robbed one day, and if by the next day the robber was caught and all your goods returned to you, you would only feel partly restored; you would be ''cured'' but not ''healed''; your sense of psychic violation would remain. Similarly with illness, a cure is good, but we want the healing as well, we want the magic that good physicians provide with their personality, their empathy and their reassurance. Perhaps these were qualities that existed in abundance in the prepenicillin days when there was little else to do. But in these days of gene therapy, increasing specialization, managed care and major time constraints, there is a tendency to focus on the illness, the cure, the magic of saving a life.

Science needs to be more cognizant of the other magic, the healing if you will, even as we reach for the proven cures. We need to develop and refine that magic of the physician-patient relationship that complements the precise pharmacologic interventions we may prescribe; we need to ensure the wholeness of our encounter with patients; we need to not lose sight of the word ''caring'' in our care of the patient. And doggedly, in this fashion, one patient at a time, we can restore faith in the fantastic advances of science we are privileged to witness.

And healing takes time. Insurers (I certainly love to pick on them) do not reimburse healing. Maybe this is the fundamental flaw in how we finance medical care.

Some Tentative First Steps Toward Universal Health Care. Please read the article from the NY Times. The insurance companies are worried (as well they should be).

Many health plans are developing or offering insurance with lower premiums and slimmer coverage to attract customers who cannot afford more comprehensive policies. Executives at Blue Cross Blue Shield of Montana are pressing state legislators to raise the cigarette tax to subsidize basic coverage. Another insurer, Blue Shield of California, proposed a plan this week for health insurance for all state residents. And Dr. William W. McGuire, chief executive of the UnitedHealth Group, the largest private insurer, has written to every member of Congress calling for "essential health care for all Americans."

Health insurers, which have long ranked high among the country's most disliked businesses, frame many of their proposals in public policy terms. But they also have strong business reasons to become involved in the debate over helping the uninsured. They want to add young, healthy members to their insurance pools to spread the cost of caring for the sick. They are also eager to add members whose premiums would be paid with tax money or government subsidies.

Several insurance executives also said pressures generated by the uninsured were raising a threat to the system that could lead to government intervention if insurers did not develop a plan first.

"If we don't do something in a darn hurry about the uninsured, the whole health care system in this country is going to collapse and the government will step in," said Chuck Butler, a vice president of Blue Cross Blue Shield of Montana. "People will say, enough is enough."

We need more creative solutions. Readers added several excellent comments to yesterday's stories. MSAs (medical savings accounts) could be a method, however, one needs money to have such an account.

With insurers pushing and I suspect physicians not far behind, we should have some experiments started in the near future. I prefer the demonstration project approach then instant national policy. We must understand the intended and unintended consequences of any proposal. Unintended consequences are much easier to see in retrospect!

This article and the following one should represent major clues. Who is trying to solve the puzzle? PATIENTS IN PERIL: Many doctors reject HMO clients, UCSF survey says

A survey by UCSF researchers warns that California's managed care system may be unraveling as growing numbers of independent physicians, unhappy with low fees, refuse to take on new HMO patients, making it harder for even the fully insured to find a doctor.

The report by Dr. Kevin Grumbach and colleagues at UCSF's Center for the Health Professions found that only 58 percent of California doctors are accepting new patients who are covered by a health maintenance organization.

That means that privately insured HMO patients are having almost as difficult a time finding a new doctor as recipients of Medi-Cal, the state and federally funded health insurance program for the poor. The survey found only 50 percent of primary care physicians were accepting new patients for Medi-Cal, a program notorious for the low rates it pays health providers.

We are developing a shortage of physicians. We are training too few to replace those who are leaving the working physician pool. Physicians cannot continue to see patients at a loss. The numbers do not add up.

Malpractice reform is needed. We need to control the ever increasing overhead costs. And we need to right size the payments for an office visit.

Strapped Doctors Offer Less Charity Care

The portion of doctors providing charity care is falling, a sign of tight times that make it harder for the uninsured to get health care.

Most doctors do some charity care but in most cases it represents a small fraction of their work. The portion spending more than 5 percent of their time with these patients is falling, however.

Physicians are under a lot of growing financial pressures," said Peter Cunningham, who wrote the report for the Center for Studying Health System Change, a health policy think tank that conducts the ongoing survey of doctors. "This may be making it more difficult to serve uninsured patients."

...

The survey of doctors found that the portion seeing Medicaid patients dipped between 1997 and 2001, from 87.1 percent to 85.4 percent. But it also found an increase in the number of practices that derived more than 20 percent of their income from Medicaid, suggesting the Medicaid patients are concentrating among fewer doctors.

Not so for those providing charity care. In this case, the portion of high-volume providers fell, while the portion of low-volume providers rose. That means that doctors who do provide charity care were providing less of it – and fewer total doctors were providing any at all.

The survey also found that doctors who are heavily involved with managed care – receiving more than 75 percent of their income from health maintenance organizations and other plans that cap payments – are more likely to have closed their practices to new Medicaid and Medicare patients. These same practices were still taking new privately insured patients.

And Nero fiddles!

The answer is in - atrial fibrillation patients do just as well and maybe better when treated with rate control and warfarin. 2 Studies Point to Altered Approach on Atrial Fibrillation. These results are big news. The studies should alter how we consider this very common arrhythmia.

The studies, being reported today in The New England Journal of Medicine, found that less costly and safer drugs that adjust the heart's rate, the speed at which it beats, are as effective as other drugs and procedures that control its rhythm, the regularity of that beat.

Among the subjects, the rate therapy also led to fewer hospital admissions, presumably because of fewer side effects than from the rhythm-control drugs.

Until now, most American doctors have preferred a treatment strategy of restoring a normal heart rhythm, which can involve electrically shocking the heart, partly on the presumption that it lowered the incidence of complications like strokes more than with the heart-rate strategy. But the prevailing approach was largely uncontested, based on intuition rather than scientific study.

We have known for some time that 'rhythm control drugs - anti-arrhythmics' are complex often side effect laden drugs. Proponents argued that sinus rhythm improved quality of life and patient well being. Apparently rate control is good enough.

The new reports also underscore the importance of prescribing and carefully monitoring anticoagulant drugs to reduce the chances of the formation of blood clots, whatever the treatment strategy.

The danger from the blood clots promoted by atrial fibrillation is that pieces of clots will break off to lodge in arteries in the brain, causing strokes, or elsewhere in the body, damaging organs. In the studies, strokes tended to occur among those taking inadequate doses of anticoagulant drugs like warfarin (sold under the brand name Coumadin) or not taking them at all. Anticoagulants showed benefit even if the heart rhythm returned to normal.

This ia not news. We know from many studies that patients with atrial fibrillation need anticoagulation to prevent thrombotic complications. However, these studies do strongly reinforce that message.

Medical knowledge generally moves somewhat slowly and then we have the occasional quantum leap. These articles represent a quantum leap in our knowledge. They are practice defining articles.

Managed care mars quality of education: Medical school faculty struggle to find time for students and research. This is no surprise to me as a faculty member. Fortunately, we have much less managed care in Alabama and thus have less of this effect.

In a newly released report, many directors said managed care made health care more like a commodity and reduced professionalism. The report, "Clerkship Directors' Perceptions of the Effects of Managed Care on Medical Students' Education," was published in the November Academic Medicine.

"It's an important study because it comes the closest to proving that there are real problems in medical student education that are attributable to managed care. Because of that, the health care of the future may be in jeopardy," said Amy C. Brodkey, MD, the study's lead investigator and a clinical associate professor in the Dept. of Psychiatry at the University of Pennsylvania in Philadelphia.

The American Assn. of Health Plans said the report is another jab at managed care.

"There has been a movement in the last several years and a tendency of the health care industry as a whole to lay all the problems at the doorstep of managed care," said AAHP spokesman Mohit Ghose, who pointed out that the survey on which the article is based is 5 years old.

Dr. Brodkey and the Alliance for Clinical Education, which conducted the study, said the opinions of clerkship directors have not changed. The alliance is made up of seven organizations that direct core clinical clerkships in most medical schools.

"Given the further penetration of managed care into academic medical centers since the time of this study, I would predict that this situation will only get worse," Dr. Brodkey said.

Recently I endorsed working with a personal trainer if one is naive about resistance training. I assumed in that recommendation that one could find a QUALIFIED personal trainer easily. This article discusses the problems of finding the right trainer. Who Trained the Trainer? : As Fitness Credentials Differ, So Do Knowledge And Safety. The facility that I use has a very structured training program. I know the owners (who are very experienced trainers themselves) and have seen them training new trainers. This model is an unusual one though. If you are looking for a trainer, read this article carefully.

Fast Food and the Obesity Problem. Nice piece (in the advertising section) which comments on the implications of the McDonald's lawsuits. This article discusses the advertising and marketting implications. Perhaps the lawsuits are having their intended effect; perhaps these suits are not about winning money.

Dietary Advice Takes On Mediterranean Flavor

The most significant change in thinking — one, admittedly, that is still vigorously debated — is that low-fat is not the answer, or at least, not the best answer.

But before you say "I told you so" and go back to eating all the steak, butter and eggs you want, a careful analysis of the evidence clearly shows that it is not a high-fat, low-carbohydrate diet that is protective.

Rather, it is a diet like the one consumed by heart-healthy people along the Mediterranean: rich in vegetables and fruits, whole grains, nuts, unsaturated vegetable oils and protein derived from fish, beans and chicken, not red meat.

"Compelling" evidence for this view was thoroughly reviewed last week in The Journal of the American Medical Association by Dr. Frank B. Hu and Dr. Walter C. Willett, nutrition and epidemiology experts at the Harvard School of Public Health, who have followed tens of thousands of Americans for decades to uncover relationships between diet, habits and health.

New pyramid is built on disease prevention

The food guide pyramid needs to be rebuilt if Americans are to significantly cut their risk of chronic diseases, Harvard researchers say.

They designed and tested a new pyramid, one that emphasizes fiber from whole grains rather than refined ones, white meat (fish or chicken) over red and unsaturated fats over saturated ones. It also suggests alternate protein sources, such as nuts and soy, a multivitamin and moderate alcohol intake. The U.S. Department of Agriculture pyramid and the Harvard one emphasize fruits and vegetables.

The researchers analyzed responses of 100,000 men and women to food questionnaires completed periodically over 10 years. Because the volunteers were participating in long-term health studies, data about their illnesses were also available.

Using the Alternative Healthy Eating Index, a scoring system that measured how closely volunteers' diets matched the new guidelines, the researchers found that men with the highest scores lowered their risk of chronic diseases by 20%, compared with participants with the lowest scores and that women cut their risk by 11%. Previously, the researchers had found that adhering to the USDA guidelines reduced the risk by 11% for men and 3% for women. The biggest effect of the new guidelines was on heart disease, the researchers said. "The reduction in risk was twice as strong as when we evaluated the USDA guidelines," says coauthor Marji McCullough, a researcher at the American Cancer Society in Atlanta.

The study was published in the December issue of the American Journal of Clinical Nutrition.

Figuring out the right healthy diet remains a challenge. I do try to adhere to the multigrains and less red meat. I believe it probably does make a difference.

Clinical trials are suffering

Clinical trials are essential to medical progress -- they're the only way of testing whether new drugs, surgical techniques or experimental devices actually work. But researchers are finding it increasingly difficult to find volunteers. A new study illuminates part of the problem. Americans are deeply suspicious of medical research, it found, and don't trust their doctors to protect them from unnecessary risks when prescribing treatment.

"This is really an indictment of medical research," said Dr. Giselle Corbie-Smith, co-author of the study published last week in the Archives of Internal Medicine. "If individuals distrust the research enterprise and are unwilling to participate in it, it could impede patient recruitment for clinical trials."

But is this really an indictment of medical research or rather an expected side effect of high profile law suits. Admittedly, serious mistakes are made in medical research. To indict the entire field because of those mistakes seems short sighted. Every action has consequences - some expected some unexpected. Medical researchers try to understand those consequences. Those who sue when mistakes are made have their own individual rights, but someone (or many someones) will suffer in the future from the lack of important information.

A reader writes "past 60, I understand that weight lifting helps strength, balance, and bones. However, there is a proper way to do this, or one can damage muscle etc. Where do we find the instructions??". There are several ways one can proceed. Being past 50, I find this an excellent question. The questioners assumptions of the benefits are correct.

The best (although more expensive) way is to work with a qualified personal trainer. Personal trainers can help you pick strength training exercises and emphasize proper technique. I use a personal trainer and am very pleased with my results - improved strength, decreased body fat and greater sense of well being. However working with a personal trainer is not an option for everyone.

In researching this topic, I found this highly recommended book - Strength Training Past 50

Muscles lose size and strength with age, resulting in physical weakness and a variety of degenerative problems. But muscle loss may be largely avoided with regular strength training, and a large amount of muscle tissue already lost can be replaced, regardless of your age. Strength Training Past 50 presents research-based guidelines to help anyone over 50 develop and perform a sound, safe strength training program.

Wayne Westcott, PhD, and Tom Baechle, EdD, two of the world's most recognized strength and conditioning experts, have developed this comprehensive, practical guide for the over-50 fitness market, one of the fastest-growing segments of the industry.

Wayne Westcott is one of the fitness industry's most visible and respected experts, whose articles have appeared in Shape, Fitness, Prevention, Men's Health, and other popular publications and whose research has contributed much of the mounting evidence showing the great benefits of strength training for people past 50. Tom Baechle is the author of Weight Training: Steps to Success, which has sold more than 100,000 copies, as well as several other books. He is also editor of Essentials of Strength Training and Conditioning, the definitive text in its field.

Strength Training Past 50 uses data collected and analyzed in a five-year study that examined the effects of regular strength training on previously sedentary adults. Results showed that regardless of gender, age, or physical condition, the 1,132 men and women who participated in the strength exercise program made significant improvements in terms of added muscle, lost fat, and reduced resting blood pressure. In fact, in this group, in which the age range was 21 to 80, participants over 60 responded just as well to strength exercise as everyone else.

Research clearly shows that you're never too old to get great benefits from strength training. Strength Training Past 50 explains and shows the most effective way for mature adults to work their muscles by presenting

* specific strength tests,
* 9 safety essentials,
* 39 age-appropriate exercises,
* a 10-week workout plan, and
* personalized programs for increasing muscle size, strength, or endurance.

Flu Season Is Upon Us . This column provides excellent information on flu shots. I always get one as soon as the arrive. As a health care worker, I am more likely exposed to the flu, and if I was infected could infect some very sick patients.

Lots of people self-diagnose "flu" when, in fact, what they have is a variation on a common viral respiratory infection, a.k.a. the common cold. True flu comes on very rapidly with fever, chills, weakness, muscle aches and a cough that is very hard to control. The fever and the really awful symptoms usually subside within a week, but the cough can go on for months.

Most flu comes in epidemics. Isolated cases are relatively rare. Very few flu sufferers develop significant stomach or abdominal problems; what is commonly called "stomach flu" is caused by an unrelated virus and is more properly called viral gastroenteritis.

True influenza is a very serious infection with a relatively high mortality rate. If you should receive this immunization please do it soon.