I am changing my blogging tool – but the changes will remain opaque to the reader (other than a couple of minor enhancements). I am on the road, and probably won’t blog again until Monday evening.

Gene is linked to heart attacks

They found that a particular mutation of the gene occurs more frequently in people who have had a heart attack.

It is thought the gene controls inflammation in the arteries supplying blood to the heart. A blockage here can trigger a heart attack.

The research, by Toyko’s Institute of Physical and Chemical Research, is published in Nature.

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The heart attack patients were significantly more likely to carry a specific mutation in a gene that produces a protein called galectin-2.

Galectin-2 is known to bind to a molecule that assists inflammation – lymphtoxin-alpha (LTA) – and which is released when a coronary artery ruptures.

The gene mutation appears to change galectin-2, and in turn to affect the amount of LTA that is secreted – possibly boosting inflammation and increasing the risk of a heart attack.

Professor Jeremy Pearson, of the British Heart Foundation, said: “Over the last decade or so, scientists have realised that the fatty deposits (atherosclerosis) which accumulate in blood vessels are in fact due to a chronic inflammatory disease.

“The current paper strengthens this view, with the novel implication that genes which can control the release of inflammatory proteins from cells may also be related to heart disease risk.”

While preliminary data, this research suggests that our thoughts about a cardiac inflammatory response make sense. As we better understand this response, and associated factors, so might we better screen and prevent coronary artery disease manifestations.

Fascinating article in today’s Wall Street Journal (A2 column). Thanks to a very nice reader who called my attention to the column. For those with a subscription – The Misconceptions About Drug Prices

The Bush administration thinks more of the free market would be better, and makes one observation that hasn’t received much public attention. Brand-name drug prices are lower abroad because governments won’t let the market set prices, but prices of generic drugs — those for which the patent has expired — are higher for the same reason. He argues that other countries deny themselves the benefits of cheap generics. While generics account for half of all prescriptions in the U.S., they are less than 40% in Canada and less than 10% in France, he notes.

The point, too often overlooked in the debate about allowing more imports of prescription drugs, is that the U.S. will run into trouble if it tries to adopt only parts of other countries’ approach to drug prices.

The U.S. spends more on drugs: $556 per person in 2000 versus $473 in France, $385 in Canada and $252 in Australia, the Organization for Economic Cooperation and Development reports. But because the U.S. spends even more on other health care, drugs are a bigger share of health spending elsewhere: 12.4% of all health spending in the U.S. versus 21% in France, 16.2% in Canada and 13.8% in Australia.

These data certainly stimulate ones thinking. We do want less expensive trade name drugs. The goal seems reasonable. However, we can function well within the current system. We (physicians) have a great array of generics to prescribe. Judicious use of generics will certainly help patient expenditures on drugs.

Surgery carries many risks. One is the risk of inducing a cardiac event (probable stimulated by stress). We know that beta blockers decrease the risk of post-surgical mortality (especially in patients at high risk for coronary artery disease). Now we have epidemiologic data suggesting that statins may also offer some protection.

Lipid-Lowering Therapy May Reduce Mortality After Major Surgery

“Statins have been shown to have a number of effects that may help stabilize atherosclerotic plaques,” Dr. Lindenauer noted. “Since rupture of such plaques is thought to be responsible for most postoperative myocardial infarctions and other adverse events,” it seemed logical to look at the effect of lipid-lowering therapy on mortality after surgery, he added.

The results are based on a study of more than 780,000 patients who underwent major noncardiac surgery in the US during 2000 and 2001. The operations included a variety of general, gynecologic, and specialist procedures. Patients who used lipid-lowering agents on the first or second hospital day were classified as users.

Overall, 2.96% of patients died during hospitalization, the authors report. The mortality rate for patients treated with lipid-lowering agents was 2.18%, significantly lower than the 3.15% rate seen for nonusers (p < 0.001). The reduction in mortality was more pronounced with statins than with other lipid-lowering agents.

Based on the risk reduction seen with lipid-lowering therapy, 85 patients would need to be treated with such drugs to prevent one postoperative death. For lower risk patients, the number needed to treat increased to 186, whereas for higher risk patients only 30 were needed to prevent one death.

So, should every patient undergoing major surgery now receive lipid-lowering therapy? Dr. Lindenauer believes that it is too early to make this conclusion. “Our study was observational and I think the findings really need to be confirmed in a randomized clinical trial.”

Thus, we have interesting data founded in solid theory. But, as the investigator cautions, we still need a prospective study prior to widespread adoption of this new strategy.

I always wondered where this quote originated.

“If the only tool you have is a hammer, you tend to see every problem as a nail.” — Abraham Maslow (1908-70), American psychologist, founder humanistic psychology

We generalists often use this quotation to describe subspecialty behavior. Sometimes we are right!

Seniors need strength training, too

Many people think that beyond a certain age, you become too weak to strength train or benefit from it. But research shows the complete opposite. Without adequate muscle exercise, most adults lose 20 to 40 percent of the muscle they had as young adults. With too much muscle loss people have difficulties performing daily activities that allow them to live independently.

Experts say that even small gains in muscle – too small to see – can make significant differences in how seniors live. Strength training can affect whether an older person can get out of a chair without help. It can also influence their sense of balance, risk of falls and fractures, and the ability to climb stairs or carry groceries. Strength training can even make bones stronger and weight control easier.

One recent study of seniors showed that after six months of strength training, strength in a variety of muscle groups increased 31 percent for the duration of the two-year study. Other studies show benefits for the frail elderly living in nursing homes. People who had formerly needed walkers to get around could use a cane instead.

I extrapolate and believe that we 50somethings should do resistance training as primary prevention. And I do.

Many patients who develop coronary artery disease have well known major risk factors. These include smoking, family history, high LDL cholesterol, diabetes mellitus, low HDL and hypertension. However, these risk factors do not explain all coronary artery disease. Recent research has expanded our ideas about etiology and risk.

This Washington Post article does a nice job summarizing our emerging understanding of risk factors. Not Your Father’s Heart Attack

• As many as one of every five heart attacks occurs among apparently healthy individuals who have none of the major risk factors: smoking, high blood pressure, high cholesterol and diabetes.

• Half of all heart attacks happen to men who don’t have high cholesterol, the most anxiously tracked risk factor.

• Most confounding: While the vast majority of men diagnosed with heart disease are known to have at least one risk factor, it’s also true that the vast majority of men with one risk factor don’t have heart disease.

“What we don’t yet understand is, of those patients who do have the traditional risk factors, which [patients] are the ones who are going to have an event,” said John Canto, a cardiologist at the Watson Clinic in Lakeland, Fla., and author of a Journal of the American Medical Association (JAMA) editorial about heart disease risk factors.

Researchers are turning their attention to new markers — novel risk factors, as they are known — to fine-tune predictions of who is headed for that first, or second, heart attack. They are also refining their understanding of some traditional risk factors. Following is a summary of the latest research into risk factors over which men have some control. None can yet predict with certainty whether you’re a heart attack waiting to happen. But each can contribute to a portrait of your overall risk.

I recommend this article as a nice summary of an important topic.

With all the furor over anabolic steroids and ephedrine, creatine remains the leading supplement for weight training. I hesitate to label creatine a supplement, but it actually fits the title very well. We all make creatine naturally. Extra creatine (whether dietary or in supplementation) seems to allow weight lifters to lift heavier weights. This leads to increased muscle growth, because the creatine allows the athlete to handle increased loads – leading to more growth.

Numerous studies show creatine safe and effective. This article summarizes the data well – The creatine edge

I have chosen to not take creatine myself, because I do not see a reason to supplement my muscle growth. I cannot criticize those who use it, as this supplement does have good safety data. However, like all supplements, bioavailability and consistent dosing are problematic – because the industry is not well regulated.

Demonizing Fat in the War on Weight

But a growing group of historians and cultural critics who study fat say this obsession is based less on science than on morality. Insidious attitudes about politics, sex, race or class are at the heart of the frenzy over obesity, these scholars say, a frenzy they see as comparable to the Salem witch trials, McCarthyism and even the eugenics movement.

“We are in a moral panic about obesity,” said Sander L. Gilman, distinguished professor of liberal arts, sciences and medicine at the University of Illinois in Chicago and the author of “Fat Boys: A Slim Book,” published last month by the University of Nebraska Press. “People are saying, `Fat is the doom of Western civilization.’ ”

Now, says Peter Stearns, a leading historian in the field, the rising concern with obesity “is triggering a new burst of scholarship.” These researchers don’t condone morbid obesity, but they do focus on the ways the definition of obesity and its meaning have shifted, often arbitrarily, throughout history.

Mr. Stearns, provost and professor of history at George Mason University, has written that plumpness was once associated with “good health in a time when many of the most troubling diseases were wasting diseases like tuberculosis.” He traces the equation of obesity and moral deficiency to the late-19th and early-20th centuries. In 1914, an article in the magazine Living Age, for example, stated, “Fat is now regarded as an indiscretion and almost a crime.” Mr. Stearns cites it in an essay he wrote for the aptly named “Cultures of the Abdomen,” a collection to be published by Palgrave Macmillan next November, edited by Christopher E. Forth, a senior lecturer at Australian National University, and Ana Carden-Coyne, a lecturer at the University of Manchester, in England. During World War I, Mr. Stearns writes, some popular magazines actually said that eating too much and gaining weight were unpatriotic, presumably because of concerns about food shortages.

A great example of this “movement” – The big fat con story

Size really doesn’t matter. You can be just as healthy if you’re fat as you can if you’re slender. And don’t let the obesity ‘experts’ persuade you otherwise, argues Paul Campos

His book – The Obesity Myth – represents his treatise on this issue. The article summarizes his argument.

Several important points need addressing. We can ignore the argument about BMI. Yes, many healthy athletes have elevated BMI. We should focus our definition more on fat percentage or waist circumference. Second, when we do that, we find that as fat increases, so does the risk of type II diabetes mellitus (and therefore atherosclerotic complications) and obstructive sleep apnea. Anyone you makes rounds with me for a month would see the devastation that those disease cause.

Physicians are not making a moral argument, rather we are focusing on prevention. When we have patients exercise and lose fat, their outcomes improve. Admittedly, we need a new method to achieve that goal.

Health Care Blog comments favorably on a critique of the malpractice system – QUALITY/MALPRACTICE: Change malpractice system to patient safety system, say Pfizer doc. He references an article from Health Politics – The Road from Medical Malpractice to Safety: You Can’t Get There from Here. Quoting from the original article:

A head-to-head comparison tells the story. The tort system uses litigation as its lever for change. The safety movement uses quality improvement analysis. Tort law focuses on the individual. Safety focuses on the process. The tort system’s punitive and adversarial style drives information down, encouraging secrecy. The safety movement uses a non-punitive and collaborative approach, which encourages openness, transparency, and continuous improvement. With tort law, exposing oneself can end one’s career and harm one’s mental health. In the safety movement, contributing is career-enhancing and therapeutic.

It may seem counterintuitive, but for medical malpractice to achieve its stated social purpose it must abandon the emphasis on a tort-based approach and embrace safety. Alternate dispute resolution, no-fault systems, raising fault to the institutional level, and exploring the use of medical courts all merit consideration and could begin to break the cycle of blame and provide a level of security necessary to ensure openness and transparency.

I do believe that most physicians would endorse a true safety process. The Health Care Blog finishes their rant

The AMA and the rest of organized medicine need to take the lead here, get off their high horse about the malpractice issue, and while they have a very sympathetic (i.e. Republican) Congress, develop some real bipartisan consensus on replacing the current tort system with a legally mandated patient safety system. That system will need real teeth to assure the public that it’s not biased in favor of physicians and providers. And of course we need a neutral public education campaign about why such a system is required; reason number one being that most malpractice currently goes on unimpeded, and this system will stop that.

Physicians support malpractice reform – including a safety system. Do not attack physicians and Republicans here. Rather attack the Democrats and the trial lawyers who apparently have no interest in safety, rather an interest in the tort process.