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.

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!

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.

Recently, a reader wrote to ask if I allowed "guest rants". The reader wanted to rant against vaccinations.

I do not allow guest rants, this page is my ranting place. You can comment, but I chose the rants.

I had not thought much about the request until I came across this article - Anti-Vaccination Fever. The author relates the story of pertussis (whooping cough) and how the anti-vaccination lobby has allowed this disease to make a comeback.

Distorted numbers, confusion of correlation with causation, and statistical innumeracy certainly played roles in this sad story. Sensationalist media campaigns fanned the glowing embers. But in each of the countries that experienced the raging fires of epidemics there were other forces at work. Most prominent in passive anti-vaccination movements were religious groups whose opposition was based on religious or moral grounds. Prominent in both passive and active anti-vaccination movements are followers and practitioners of homeopathy, chiropractic, and natural and alternative medicine (Gangarosa et al. 1998).

Despite the compelling case for vaccination that the anti-pertussis vaccination movement has inadvertently made, the Ström, Kuhlenkampff, and Stewart papers are still frequently cited in anti-vaccination literature. Speaking to Science News, Eugene Gangarosa, of Emory University, had this to say of anti-vaccine movements: "There's no question these movements undermine, collectively and individually, the benefits of vaccination" (Christensen 2001).

When anti-vaccination alarm takes hold-characterized by sudden attacks of the media, mistaken researchers, fervent religious groups, and alternative medicine quacks-the infected society begins to make horrid, whoppingly bad decisions. There is, as yet, no Latin name for this peculiar social disease.

Read this fascinating, albeit technical, exposition.

Too often, new surgical techniques do not receive a careful analysis. The VA came through to answer an important question - what is the best approach to hernia repair - Open Mesh Better Than Laparoscopic Mesh Inguinal Herniorrhaphy

Of 2,164 men with inguinal hernias enrolled from one of 14 VA medical centers and randomized to open or laparoscopic repair, 1,983 had surgery, and 1,696 (85.5%) completed two-year follow-up.

There were recurrences in 87 (10.1%) of 862 patients in the laparoscopic repair group and in 41 (4.9%) of 834 patients in the open repair group (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.5 - 3.2). Complications occurred in 39.0% of the laparoscopic repair group and in 33.4% of the open repair group (adjusted OR, 1.3; 95% CI, 1.1 - 1.6).

However, the laparoscopic repair group fared better than the open repair group in terms of pain on a visual analog scale on the day of surgery (difference in mean score, 10.2 mm; 95% CI, 4.8 - 15.6) and at two weeks (6.1 mm; 95% CI, 1.7 - 10.5), and they returned to normal activities one day earlier (adjusted OR, 1.2; 95% CI, 1.1 - 1.3).

Rates of recurrence after repair of recurrent hernias were similar in both groups (10.0% vs. 14.1%). In prespecified analyses, the surgical approach (open or laparoscopic) was associated with the type of hernia (primary or recurrent) (P = .012).

For laparoscopic repair, the recurrence rate was less than 5% for 20 surgeons in the study who reported having done more than 250 of these procedures, but it was consistently above 10% for 58 laparoscopic surgeons who reported less experience with this type of repair. Outcomes of open surgery were far less dependent on the surgeon's experience.

Study limitations include a nonrepresentative sample of high average age and low health-related quality of life; self-reporting of surgeons' experience; and exclusion of patients who had previously undergone a hernia repair using mesh.

Surgical studies are always difficult. This study does remind us that we can not randomize surgical skill. Some surgeons obtain better results than others. The wise generalist figures out which surgeons to whom he/she should refer.

If patients need major surgery, they should try to find outcomes if at all possible. At least use a surgeon with significant experience doing that procedure.

Answer, but No Cure, for a Social Disorder That Isolates Many

Task Force Redefines the Domain of General Internal Medicine

The Society of General Internal Medicine (SGIM) asked a task force to redefine the domain of general internal medicine. The recommendations of the Task Force on the Domain of General Internal Medicine (DGIM) are published in the April 20 issue of the Annals of Internal Medicine, along with editorials providing additional opinions.

"The [SGIM] believes that the chaos and dysfunction that characterize today's medical care and the challenges facing general internal medicine should spur innovation," write Eric B. Larson, MD, MPH, from the Group Health Cooperative, Center for Health Studies in Seattle, Washington, and colleagues from the SGIM Task Force on the DGIM. "Remaining true to its core values and competencies, general internal medicine should stay both broad and deep, ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases."

Specific recommendations are that postgraduate and continuing education should develop mastery, enabling general internists wherever they may practice to lead teams and be responsible for team care, to embrace changes in information systems, and to provide most of the care required by their patients.

Fee-for-service and other physician reimbursements should be changed to recognize the value of services performed outside the traditional face-to-face visit, and to offer incentives to improve quality and efficiency and to provide comprehensive, ongoing care. Options could include giving physicians a patient management fee plus reimbursement for specific services, or a salary with incentives for productivity, quality, and improved outcomes.

Residency training in general internal medicine should provide both broad and deep medical knowledge, including mastery of informatics, management, and team leadership. The final one to two years of residency training should be flexible and based on practice goals, leading to a certificate of added qualification in generalist fields.

Research initiatives should include practice and operations management, focused on more effective shared decision-making, transparent medical records, and closer personal connection between physicians and patients.

"The task force believes that these changes will benefit patients and the public and reenergize general internal medicine," the authors write. "Our field must adapt to a new world of consumerism, rising public expectations, widespread information dissemination, and contradictory pressures to hold down costs at a time when the demand for services is increasing because more people survive to old age with chronic disease."

I had the opportunity to read and comment on this report during its construction. Like any such report I can find areas which I dislike. On balance though, SGIM has taken an important initiative to address the important question of how to reinvigorate general internal medicine.

A careful reading will reveal many issues that we discuss in this blog. I always try to take such reports in context of the old Southern saying: "If it ain't broke, don't fix it!"

Well, generalist care is broken, and thus requires remedies. I certainly hope that this report focuses the debate. We need a healthy discussion to develop more functional solutions to generalism.

I like this case a great deal. Read it carefully, and see how quickly you can make the diagnosis. Tunnel Vision, Cramped Hands, Nausea

As we discuss type II diabetic patients, we generally assume that they have coronary artery disease unless we have proven that they do not. Atherosclerotic complications occur very frequently in patients having type II diabetes. Current guidelines also make this assumption. Now we have a strong recommendation concerning statins in these patients.

Treatments: Statins and Diabetes: New Advice

Most patients with Type 2 diabetes should start taking statins, the cholesterol-fighting drugs, as a preventive measure against heart disease, whether or not they have high cholesterol levels, according to new guidelines released yesterday.

The recommendations, from the American College of Physicians, call for moderate doses of statins by people with diabetes who are older than 55, and for younger patients who have any other risk factor for heart disease, like high blood pressure or a history of smoking.

The new guidelines are outlined in April 20 issue of The Annals of Internal Medicine, in an article that noted that about 16 million Americans have Type 2 diabetes and that 800,000 new cases are diagnosed every year.

The lead author of an article accompanying the guidelines, Dr. Sandeep Vijan of the University of Michigan, said that "almost everyone with Type 2 diabetes should be on a statin."

The average age at diagnosis is 48, and even many patients under 55 have high blood pressure as well as diabetes, he said.

Traditionally, diabetes treatment has focused on regulating blood sugar levels by careful control of diet or through insulin injections. But researchers have come to understand that controlling sugar really protects only against the destruction of small blood vessels, which can lead to blindness or loss of fingers, toes or limbs.

Heart disease is, in fact, the more serious threat. Up to 80 percent of diabetes patients will develop heart problems or die of them, the article said. And Dr. Vijan emphasized that controlling hypertension remained the highest priority. He ranked control of lipids, the fats in the blood stream that can affect coronary health, second, ahead of glucose regulation.

I believe that this guideline makes sense in lieu of the mounting data.

Amazing! I just ranted about this issue yesterday. This article bemoans our expenditures on hypertension management - Following Evidence-Based Hypertension Guidelines Could Save Billions. Great! We can do a better job!

As they say on the Guiness commercial (I only wish that I could get some royalties here) - BRILLIANT! .

Quit bemoaning, and develop strategies to fix the problem. Identifying the problem is not enough. These researchers (who are excellent and well regarded) must address solutions.

If they do that, then it really will be BRILLIANT! .

I love General Internal Medicine - both outpatient and inpatient. The intellectual and patient interaction challenges never diminish.

We must maintain broad knowledge and develop the skills to apply that knowledge to our patients. Unfortunately, most physicians can improve their performance.

However, I am often frustrated by the repeated complaints about generalist performance. Here are the two most recent examples:

CDC: Fewer doctors urge weight loss and Statins Underused in High-Risk Elderly Patients

These two examples represent an entire class of such articles. What do these articles tell us? How should we interpret the articles? What should we (the medical community) do with this information?

Using the medical paradigm, one should seek more than making a diagnosis. One should consider the possibilities of treatment. Moreover, we should not stop at making a diagnosis. We must understand what causes the problem.

Consider outpatient medical practice. Each day we see multiple patients with multiple medical problems. Each patient requires attention to a variety of medical problems, including the interaction of those problems. In addition to those problems, we must consider a variety of preventive measures. Careful consideration of all issues might take as long as 30-40 minutes for some patients. But our current reimbursement system dictates shorter visits. Our current reimbursement system dictates seeing too many patients.

Any interest group (and yes the CDC report on obesity represents an interest group) can seek and find deficiencies. However, I do not see much work on helping diagnose and treat the problem. We focus on symptoms, but do not understand the disease.

Thus, I decry these articles. They are no longer constructive, rather they are destructive.

We need a new attitude amongst the health services research community. Quit looking for deficiencies, rather focus on diagnosing and improving health care provision. We need constructive approaches to outpatient and inpatient care. We need to improve.

If I am slicing my drives, I go to my golf pro to diagnose why, and then work on techniques to improve my drives. If the pro just tells my that I have a lousy swing, but does not teach me how to improve, I would likely look for another pro (I say likely, because some golfers are not willing to really try to improve).

Our research group has a committment to understanding medical practice and the barriers to meeting guidelines. We hope to find solutions. I believe that rather than moan about errors and deficiencies, we should champion successes. We can learn more from the positives than the negatives. Physicians will strive towards excellence. Show us how!

Physicians are damned if we underprescribe narcotics to pain patients, and damned if we prescribe to those who abuse drugs. Some pharmaceutical companies are trying to make oral narcotics effective, yet not abusable. Drug Makers Hope to Kill the Kick in Pain Relief

Cooperating closely with government officials and pain specialists, the companies are educating doctors, rewriting warning labels and tracking pills as they move from pharmacy to patient.

They are also reformulating pills with added ingredients. One combination blocks euphoria. Another produces a nasty burning sensation.

So we may soon see effective oral pain control without the option of using the pills in alternate ways. This is good news for pain control. We need the ability to prescribe without worrying about the possibility that we are contributing to drug abuse. These pills will help those patients who really need pain relief.

The End of Primary Care

The very quality of primary care that made it so attractive is what led to its downfall. Legislators, insurance companies, even physicians themselves began to look for ways to harness the expertise of primary care doctors to expand care and limit cost. But no one seemed to recognize that the basis for these economies was the bond between patient and doctor. And without that trust, the economies of primary care were lost.

The initial and most serious blow came when H.M.O.'s persuaded primary care doctors that they should take on the role of gatekeeper. Research indicated that care provided by primary care physicians was more cost-effective than that delivered by specialists. From the insurance companies' perspective, if these doctors were already curtailing costs by getting rid of unnecessary referrals and testing, then providing them with incentives to cut costs would make the savings even greater. What could be better?

The appeal of this system for doctors was more complicated, said Dr. Steve Schroeder, a self-proclaimed card-carrying generalist and the former head of the Robert Wood Johnson Foundation. It flattered primary care physicians by placing them right where they felt they should be: deciding the best, most cost-effective options for their patients. And directing them to a specialist, if need be. That was the theory.

So one can certainly lay some blame on the insurance companies for perverting the primary care concept. However, we must take blame ourselves. We did not think through the "unintended consequences" of the gatekeeper model.

Can we save primary care? Should we save primary care?

I believe that the answer to both questions is yes. Patients need generalist physicians. We need physicians who care for the entire patient. I suspect that most of our patients understand this.

Several movements bode well. Retainer medicine speaks to the concept loudly. While some argue that retainer medicine is just a money ploy, I would argue that some patients are willing to pay to have one intelligent caring physician available, knowledgeable and capable. Similarly, the cash only practice movement shows that patients will pay for good service.

Thus, I expect primary care to transform (albeit slowly and begrudgingly). The change will take time, because few adults embrace change. But the change will help our health care.

Ephedra ban takes effect nationwide after judge rejects supplement makers' request.

The supplement makers' lawyers tried!

Unlike medications, which must be proven safe and effective before they are allowed to be sold, federal law allows dietary supplements to be marketed without any such proof. To curb a supplement, the FDA must show it poses a significant health threat.

NVE maintains that the FDA failed to prove such a threat if the supplement is taken correctly, and was swayed by the outcry over ephedra deaths.

"The FDA chose to ignore valid science that showed that there wasn't a problem," said Walter Timpone, a lawyer for NVE. "In 1999, (there were) 104 deaths as a result of aspirin ingestion. Are we going to ban aspirin now?"

I guess this judge is not impressed with sophistry.

Ordering Treatments à la Carte

Many patients reject the idea of deciding on their own treatments. Overwhelmed by a confusing array of alternatives, they do not want the added stress of being forced to make hard decisions. They turn to their physicians for guidance.

Many doctors are also uncomfortable ceding decision making authority to their patients. The BMJ, a medical journal in Britain, recently published a study showing that men differ significantly in the importance they place on trying to cure prostate cancer versus avoiding the side effects of treatment. In response to this article, angry doctors wrote into Internet sites complaining that the researchers were taking decision making authority away from physicians.

Taken to an extreme, the new way of doing things clearly goes beyond what most patients and physicians want. Still, that does not justify a return to old-fashioned paternalism. Instead, a model of shared decision making gives physicians an opportunity to practice the art of medicine in ways that help patients make choices, often by exploring patients' values enough to make individualized recommendations.

As I have struggled to communicate better with patients (dropping my television analogy, for starters), I have learned that the distinction between letting patients make decisions and making decisions for them is often very subtle.

Paternalism is not dead. Nor should we kill it. Perhaps we should develop a new category, patient directed paternalism!

Medicare Web Site to Provide Comparative Data on Prescription Medicines

Residencies pinpoint work-hour hurdles

According to an Internet survey of resident program administrators, the specialty facing the biggest compliance hurdles was surgery, with 67.7% of 105 surgical programs represented in the survey saying they were greatly challenged by the new work hours. This was followed by neurological surgery, internal medicine, ob-gyn and thoracic surgery.

The survey was conducted Jan. 28 through Feb. 17 and 117 responses were collected.

Respondents said the most difficult rule to implement was the 24-hour call period, which also allows for six additional hours for patient transfers and educational activities.

Common obstacles were adjusting residents' schedules (reported by 56% of respondents), followed by uncooperative residents (31%), lack of funding to hire more staff (29%), difficulties managing transitions from one rotation to the next (27%) and uncooperative faculty (25%).

Respondents noted other barriers, such as getting residents to accurately record their hours in a timely fashion and collecting the data necessary to verify compliance.

Acceptance by faculty and program directors was an ongoing battle for some, who found they had to continually remind all involved of the rules.

Some programs noted positive effects, such as better organization of their residency programs overall, more streamlined patient care and improved resident morale.

Those who have not gone through residencies (non-physicians) have a difficult time understanding the difficulties that these new regulations bring. The regulations conflict with long traditions. I still do not understand how and why new, seemingly arbitrary regulations were adopted without testing.

Perhaps residencies will improve. Perhaps our trainees will become better doctors. But we do not know what the long term effect of these rules.

We continue to work to improve our residency while meeting the regulations. We hope for positive results.

Alert warns of Medicare conflict for concierge practices

Those who start concierge practices (I prefer the term retainer practice) must carefully examine Medicare billing rules. One can still bill Medicare, however, one must be very careful not to claim that the retainer fee covers any service for which the provider also bills Medicare.

Our buddy Trent McBride has stirred up a great controversy. So When Are We Going To Get That Free-Market Health Care Everyone's Complaining About? . If you find that interesting, he has 2 follow-up posts.

His rant explains (and I agree here) that we do not have a free market health care system. We have an almost nationalized health care system. Government payments and regulations prevent any free market influence (in general).

He has created quite a stir in the blogosphere. I believe that this stir shows a general misunderstanding of medical practice.

The biggest influence on medical reimbursement is Medicare (unless you do pediatrics). When they develop reimbursement, the insurers quickly follow. When they develop regulations, physicians pay.

He rightly comments on various governmental regulations which increase overhead without allowing a way to recoup those costs. Government (i.e., Congress) influences physicians and hospitals in ways which negate any free market forces.

Medicine has some exceptions - cash payments for some plastic surgeries, cosmetic dermatology, etc. However, generally, we work in a highly regulated environment. Kudos to the Proximal Tubule for starting the debate. We here at the Countercurrent Mechanism applaud his efforts.

Test Drug Said to Increase Good Cholesterol and Torcetrapib Significantly Increases HDL Cholesterol Levels. Epidemiologic data indicate that low HDL cholesterol levels put patients at a significant risk for atherosclerotic complications - coronary artery disease, stroke, peripheral vascular disease. We assume that raising the HDL would therefore decrease the risk of these conditions.

Until now, the only drug which consistently raised HDL was niacin. A new study shows that (at least under experimental conditions) one can increase HDL with a new drug.

According to the authors, another HDL-raising strategy involves the use of torcetrapib, a novel cholesteryl ester transfer protein (CETP) inhibitor. CETP is a plasma glycoprotein that facilitates the transfer of cholesteryl esters from HDL cholesterol to apolipoprotein B?containing lipoproteins.

Remember that this drug is still experimental. We must wait to learn two major things. First, how safe is this drug when taken over time. Second, does this drug improve patient outcomes.

One must always take these preliminary articles as just that - preliminary. The concept has promise. Now we must wait a few years until the appropriate studies are done.

I have received a few important comments about the match. The wife of an incoming intern wrote:

I wouldn't say most students would ask for the match. They probably keep quiet because they don't want to be branded a troublemaker and jeopardize a career they've worked so hard to make possible.

My husband just went through match 3/02 for a competitive specialty and we cursed every moment of it. Since then, it's become increasingly clear that residents often give a lot more than they get and that residency, as it exists now, works primarily to the hospital's benefit. Just a few of my complaints:

First, please read very carefully Save the Match. Second, imagine the world without a match. Who would suffer?

I proposed this question to some residents while supervising in clinic a couple of days ago. To paraphrase one, "obviously the critics have not participated in a non-match fellowship search". She shared with me her initial concerns about the match as a 4th year student. However, having just finished the interviews and acceptance of a non-match fellowship, she lamented the lack of a match in her fellowship!

The match uses the game theory which John Nash (he of a Beautiful Mind) developed. The current algorithm helps students get the highest choice which has an opening for them. It is student biased rather than hospital biased (go to the web site for links to the studies).

The match does not drive wages, or working conditions. Medicare reimbursement drives wages. ACGME and residency review committees drive working conditions.

Working conditions have improved dramatically since I graduated in 1975. I see excellent progress regularly.

I could develop a thought experiment in which working conditions might worsen at some highly desirable residencies! However, the working conditions depend more on regulatory bodies, and how the students "vote" during their match. Programs which treat their residents better tend to have better matches.

The anarchy of life without a match would (according to the web site) disadvantage couples (over 500 couples matched last year) and minorities. This protest and lawsuit are (in my opinion) poorly considered. Few would benefit from the unintended but predictable consequences of the lawsuit's success.

A Job or More School? Young Doctors Take On 'The Match'

In the suit, filed in 2002 by three former residents, the plaintiffs say graduating medical students should be able to negotiate wages and work hours. The medical associations and hospitals named as defendants in the suit contend that the match system compensates residents fairly.

The Federal District Court in Washington ruled on Feb. 11 that the residents who sued had an adequate basis to argue the existence of "a purported scheme of restraints that has the purpose and effect of fixing, artificially depressing, standardizing and stabilizing resident physician compensation."

Graduates of medical schools now sign binding work agreements with residency programs the minute they file their applications, before most hospitals have announced the wages. A new policy, to take effect next year, will require that residents be shown copies of their contracts before committing to programs.

The concern over salaries is heightened by the fact that medical students often carry enormous debts. In 2003, the average debt of a medical student was nearly $110,000, double the figure in 1993.

So why have a match? Why not have a free market for residencies?

We believe (the great majority of attendings and residents) that the match protects both applicants and programs. It allows us to go through a careful process of evaluating the many applicants to our programs and choose interns/residents in a standard way. What would happen if we had no match? (my speculation follows)

• Popular residencies could (and therefore probably would) decrease their financial stipends. To get a dermatology slot you might work for much less than today.
• Less popular residencies (either specialty or location) might increase their stipends to try to attract residents. This could lead to bidding wars - financially helping some residents in the short run.
• It follows that considerations other than the quality of training would have a greater influence on residency training
• Timing would become a greater issue. Students would start seeking positions in their 3rd year rather than their 4th year. Programs would encourage this trend to insure that they "fill" their positions. However, 3rd year students often change their minds about specialties. Thus, students might reneg on their committments, leaving programs scrambling to find replacements.
• The above comment seems absurd - until one examines subspecialty fellowships in internal medicine, which have exactly that problem.
• The stresses on applicants would increase without the current standarization

If the courts rule against the current situation, we will have increased chaos. I would suspect that most students would then ask for a match. I am certain that most programs would.

This suit might sound good to some who are not part of residency training. The destructiveness of this suit's possible success scares me greatly.

Most outpatient physicians hate insurance companies (including Medicare). Their pay scales are insulting, and the necessary overhead makes seeing patients minimally profitable. Some physicians have decided to go "old school" and eliminate the insurance companies. Some Doctors Choosing Cash Over Insurance

When Chuck O'Brien visits his doctor, they talk about his aches and pains, his heart problems and his diet, but never about his health insurance. That's because Dr. Vern Cherewatenko is one of a small but growing number of physicians across the country who are dumping complicated insurance contracts in favor of cash.

Is this the health care wave of the future? Probably not, experts say. Most people are content with monthly premiums and $10 copays; nine out of 10 doctors contract with managed-care companies. But cash-only medicine is becoming an increasingly attractive option for doctors frustrated by red tape and for the 43 million Americans who lack health insurance.

``It's a terrible indictment of the collapsing health care system,'' said Arthur Caplan, chairman of the medical ethics department at the University of Pennsylvania Medical School. ``Insurance and managed care were supposed to streamline -- instead what they've done is add so much paperwork and bureaucracy they're driving some doctors out.''

When O'Brien leaves the exam room, he writes a check for $50 and he's done -- no forms, no ID numbers, no copayments.

``This is traditional medicine. This is what America was like 30 years ago,'' said O'Brien, 55 and self-employed, who believes he has saved thousands of dollars by dropping his expensive insurance policy and paying cash. ``It's a whole world of difference.''

Health insurers downplay the trend, while emphasizing recent efforts to mend tattered relationships between doctors and managed care companies.

Cash visits make great sense for patients and physicians.

Cherewatenko, a broad-shouldered 45-year-old who wears black jackets and red stethoscopes at work, switched to cash out of desperation six years ago. His suburban Seattle practice was hemorrhaging money, and he and his partners realized they were spending hundreds of thousands of dollars just to process insurance paperwork.

``We said, 'Let's cut out this administrative waste,''' Cherewatenko said. Before, he charged $79 for an office visit and got $43 from an insurance company months later, minus the $20 in staff time it took to collect the payment. Now he charges $50 -- and he never worries about collection costs, because patients pay in full after every visit.

Cherewatenko sees fewer patients now. His whole office would probably fit inside his old waiting room. But he says the freedom is worth it.

``Accounts receivable is zero. It's a great feeling,'' Cherewatenko said. ``I feel like I'm a real doctor again.''

He started a group called SimpleCare to spread the gospel of cash-only medicine. The organization steers patients to doctors who offer cash discounts, and gives technical and moral support to doctors who want to start cutting their ties to insurance. Membership has grown to 22,000 patient members and 1,500 doctors. Some reject all insurance and take only cash, while others continue to accept insurance while offering discounts of 15 percent to 50 percent for cash-paying patients.

Independent of SimpleCare, doctors in California, Colorado, Minnesota, Texas, Mississippi and other states have also quit the insurance game. Some tired of the paperwork and administrative expenses. Some wanted to spend more time with patients without managed care bean-counters peering over their shoulders. The patients who pay cash range from poor to wealthy, with most in the blue-collar middle.

I love ideas that make sense. Read more about this movement - SimpleCare. This movement runs parallel to the retainer medicine movement. Both movements are suceeding due to patient and physician dissatisfaction with insurance and outpatient medicine. I would still advocate for "big ticket item" insurance. But perhaps this simple concept should become the norm.

Double surgery for obese 'safer'

Doctors first removed part of the stomach and then, in a separate operation, inserted a bypass in the intestines.

The first stage allowed significant weight loss so the second stage could go ahead.

A study of 75 patients was presented to the Society of American Gastrointestinal Endoscopic Surgeons.

The morbidly obese patients, aged from 23 to 72, first had a laparoscopic sleeve gastrectomy. This removes a large part of the stomach.

By performing this less drastic surgery first, mortality was greatly reduced

They were later given a gastric bypass, which involves constructing a pouch and bypassing a small segment of the intestines.

University of Pittsburgh researchers found this reduced the average body mass index (BMI) of patients by 19 points to 49 points after six months.

Interesting, but one must wonder about the side effects of the intestinal bypass. But then drastic situations sometimes require drastic solutions.

Animal research is starting to suggest some clues as to why weight loss is so difficult. Studies on a Mouse Hormone Bear on Fatness in Humans

New studies in mice suggest that the hormone leptin can fundamentally change the brain's circuitry in areas that control appetite. Leptin acts during a critical period early in life, possibly influencing how much animals eat as adults. And later in life, responding to how much fat is on an animal's body, it can again alter brain circuitry that controls how much is eaten.

Researchers say the findings, published today in the journal Science, are a surprise and add new clues to why weight control is so difficult in some humans.

Scientists knew that leptin is released by fat cells and tells the brain how much fat is on the body. They knew that animals lacking leptin become incredibly obese, as do a few humans who because of genetic mutations did not make the hormone. Leptin injections immediately made animals, and the patients with leptin deficiencies, lose their appetites. Their weight returned to normal.

But it was thought that leptin acted like most other hormones, attaching itself to brain cells and directly altering their activities.

Investigators did not anticipate that leptin could actually change connections in the brain, strengthening circuits that inhibit eating and weakening ones that spur appetite. And few considered the possibility that there might be a critical period early in life when the hormone shaped the brain's circuitry, possibly affecting appetite and obesity in adulthood.

Very interesting stuff, which may eventually help us better understand weight control.

I have read the comments. I have reconsidered the radical libertarian stand. As I absorb the hyperbole, sophistry and especially obfuscation which my debating opponents utilize, I will try to return to first principles. Primum, non nocere. - First, do no harm.

In this context, I believe that many medications, if sold over the counter, could do great harm. I am also certain that improper dosing and improper combinations of medications can do great harm.

Of course, we have pharmacists to help us prevent dangerous drug interactions - but would the libertarian position end the licensing of pharmacists. Why not sell HIV meds at the grocery store?

As I read the arguments for ending FDA controls and required physician prescribing, I see many straw men. I do not believe that one can extrapolate from many of the examples. But I will use this retort?

Should the government require a licensed engineering firm to design a bridge? Why not just let the construction company build the bridge from their experience?

Many drugs can reasonably make the transition to OTC. Many do. We better make those decisions once we have enough experience to know the safety profile of the drug. Many prescription drugs do cause problems, and are removed from the market.

We certainly can (and should) loosen restrictions on some drug classes. Other drug classes and diseases should require medical care and decision making. I do not worry about the compulsive intelligent consumer who might research his/her problem extensively and do self-dosing (although I have seen physicians cause harm to themselves with self prescribing). Those patients will at least think through the pros and cons of treating themselves (perhaps). I worry about the many patients who get advice from friends - oh, you must have CHF - try an ACE inhibitor - it worked for me.

Remember Primum non nocere should guide us. Following the radical libertarian approach would do harm to many, some of whom cannot understand the risks.

We all really know this. Talk to any smoker, and he/she will tell you that they always drink more in a bar. The physiology makes sense. Habits: A Smoke Much Sweeter

A new study has found that alcohol, even in very small amounts, appears to enhance the pleasurable effects of nicotine.

At the same time, the researchers say, nicotine may counteract some of the effects of alcohol, like drowsiness.

"It may be kind of a balancing act in the brain ? that you're taking one substance to balance the effects of another substance," said Dr. Jed E. Rose of the Nicotine Research Program at Duke University and the lead author of the study, which appears in the current issue of Nicotine & Tobacco Research.

The link between alcohol and tobacco is strong and complex. According to the researchers, as many as 90 percent of alcoholics smoke. And alcoholism is much more likely to occur among smokers than among nonsmokers, they said.

But while there has been a longstanding cultural marriage between drinking and smoking, scientists have had trouble explaining the physiological relationship. Some have theorized that alcohol lowers the ability of nicotine receptors in the brain to respond to the drug, creating a desire for more cigarettes.

While this may, in fact, occur in some receptors, the new study reports, over all, alcohol makes nicotine more pleasurable.

If researchers can better decipher this interaction, we might gain some treatment ideas. It does explain an interesting phenomenon, and provide some useful information for counseling patients.

As one commenter suggested, I have really enjoyed the comments on my paternalism rants. They have help inform my conceptualization about this subject.

If one takes a libertarian viewpoint in our society one must still understand that the limits of ones freedom end when another is harmed. The common shorthand expression - The freedom of your fist ends just short of my nose.

So the first test for restricting a medication must involve potential costs to society of improper use. Certainly all antimicrobials fit into that paradigm. The huge problem of MDR-TB (multidrug resistant tuberculosis) stems from unrestricted access and distribution of TB drugs. You may want to take your medications as you choose (or even think you have researched). However, your knowledge lack can lead to my worse illness. In fact, we take a very paternalistic view of TB in this country requiring DOT (directly observed therapy) give through public health departments.

One can certainly extend this concept to all antimicrobials - the good of many others should outweigh your desire to buy antibiotics without seeing a physician.

Admittedly, the philosophical position gets more complex when discussing cardiac medications. However, your illness improperly treated (because you chose your meds rather than having a trained physician choose those meds) costs society significant dollars - from hospitalizations, lost productivity, etc. That decision also has a significant impact on your loved ones.

Critics argue against licensing physicians and requiring proper training. I have a difficult time understanding that position. Medical care has advanced dramatically over the past 50 years. This care advances because of our training and research. We do need standards for the public good.

You can choose care from a non-physician - e.g. chiropractic care. That certainly gives you freedom. You can go to a health food store and self treat with supplements and herbs. That gives you freedom. In my opinion that also gives you substandard care.

Like many such arguments, one can take a highly controversial position and incite everyone. However, as I read the comments, that highly controversial position does not withstand careful scrutiny for our society.

Our current medical system is not perfect, but it is very good. We do improve the quality of lives. We do lengthen life spans. We cure many infections. I cannot believe that a call for anarchy will help society. Thus, your freedom to buy any medication that you desire without medical consultation could lead to societal harm. And that should be the main concern.

EKR at Educated Guesswork writes about my paternalism rant - When is paternalism justified?

I think DB is missing something important here. Sure, if you want high quality medical care and you're not medically sophisticated you want to be under the supervision of a doctor. The problem is that it's legally mandated. There's no law against me working on my own car, but when I have a transmission problem, I don't drop the tranny in my garage--I take it to a mechanic. (To tell the truth, I take it to a mechanic to have the wiper blades changed). So, I think if you want to have mandatory paternalism, you really have to explain why people aren't able to decide for themselves whether they want close monitoring. In my view, DB doesn't do that satisfactorily.

Let me try again. Many patients make their own decisions regardless of our recommendations (and remember, we prescribe we do not force feed medications). I guess a well educated patient might be able to figure out a complex medication regimen. But it really is unlikely. I guess I could treat myself - but we do have a saying about that - "The doctor who treats himself has a fool for patient".

So I must endorse this form of paternalism. Physicians have the training and experience to juggle the multiple conditions and disease manifestations. We should include the patient in our decision making - but we should recommend and recommend strongly a treatment course that best fits the available evidence. For that I do not apologize!

Paternalism In Medicine - Part II: Gatekeepers

Trent McBride writes a long rant about the influence of prescription drugs on the doctor patient relationship. First, I love the blog's title - I love renal physiology. Maybe I should rename my blog the Countercurrent Mechanism. Or that could be a great name for an alternative band!

Trent hypothesizes that making patients come to the doctor for prescriptions represents the ultimate form of paternalism. I will disagree to some extent on his proposed solutions.

Yes, prescribing medications is paternalistic. But then I do not assume that all medical paternalism is bad.

If you have congestive heart failure, I have a complex drug regimen to prescribe. Adjusting these medications requires repeated visits. I must understand the side-effects of each medicine, alone and in combination. I must consider your renal function, and your electrolytes. Finally, I must prescribe the medications with an understanding of your other medical problems (and few patients have CHF alone).

So to provide the highest quality care, I believe that I must be paternalistic. In that sense paternalism is not a bad attribute.

Narcotics might be the exception. I do not really know how much pain a patient suffers. How can I judge the best method for treating that pain? Should I worry about narcotic abuse? Wouldn't we be better off if we just let patients buy their own pain meds and suffer their own consequences?

Trent does mention antibiotics - and he is correct. But I will gladly argue that many conditions which I treat require complex decision making and adjusting of multiple medications. I accept that paternalism and I believe the great majority (>90%) of patients want that paternalism.

Caveat ahead - even when one must take a paternalistic stance, one should still discuss the rationale for each medication with the interested patient. When choices are available for treatment, we can and should discuss those choices with the patient.

So as usual, I am a bit wishy washy. I agree with some of the Tubule's argument. But I believe he goes overboard. But after all, that is what blogs are for - to stimulate our thinking and challenge accepted thinking. And therefore he succeeds.

A New Era in Treating Imaginary Ills

They make frequent doctors' appointments, demand unnecessary tests and can drive their friends and relatives — not to mention their physicians — to distraction with a seemingly endless search for reassurance. By some estimates, they may be responsible for 10 to 20 percent of the nation's staggering annual health care costs.

Yet how to deal with hypochondria, a disorder that afflicts one of every 20 Americans who visit doctors, has been one of the most stubborn puzzles in medicine. Where the patient sees physical illness, the doctor sees a psychological problem, and frustration rules on both sides of the examining room.

Recently, however, there has been a break in the impasse. New treatment strategies are offering the first hope since the ancient Greeks recognized hypochondria 24 centuries ago. Cognitive therapy, researchers reported last week, helps hypochondriacal patients evaluate and change their distorted thoughts about illness. After six 90-minute therapy sessions, the study found, 55 percent of the 102 participants were better able to do errands, drive and engage in social activities. Antidepressant medications, other studies indicate, are also proving effective.

"The hope is that with effective treatments, a diagnosis of hypochondriasis will become a more acceptable diagnosis and less a laughing matter or a cause for embarrassment," said Dr. Arthur J. Barsky, director of psychiatric research at Brigham and Women's Hospital in Boston and the lead author of the study on cognitive therapy, which appeared in the March 24 issue of The Journal of the American Medical Association.

If these patients do not induce "heart sink" then you are a different physician than me. These patient's name on your daily list causes anxiety, depression and thoughts of illness.

The biggest challenge is sorting out their hypochondriacal complaints from real disease, because even a hypochondriac can get sick.

I once had a patient who came to me after having 17 negative HIV tests. He had not had any sexual relations in over 6 months, yet thought he needed another test.

I saw this patient for around 9 months. My greatest feat was getting him back to see his psychiatrist, as he also had major depression. Over time with reassurance, calm, scheduled appoints and medication he was able to regain a productive life.

As I read the article this morning, I saw most of his personality and problems. We (physicians) would all like a consultant who wanted to see these patients, as most physicians and psychiatrists shun them. I certainly hope that these initial positive reports are confirmed.

The Limits of Opening Arteries

Experts agree that artery-opening methods ? like bypass surgery, or insertion of a balloon to mash down plaque and a wire-cage stent to keep the channel open ? can alleviate crushing chest pain and save some lives. But patients should not assume that their cardiovascular problems are "fixed" by such procedures, and patients without symptoms whose arteries are narrowing should be wary about undergoing these procedures to ward off a potential heart attack. They may have hundreds of vulnerable plaques elsewhere that are more apt to burst and trigger a heart attack than are the more stable plaques in the narrow section. Most such patients might better be treated with drugs to lower their cholesterol levels, control their blood pressure and prevent blood clots, or should adopt a healthier life style by giving up smoking, eating heart-healthy foods and exercising.

What follows represents the implications of this essay and the accumulated data that I teach on rounds. I have tried to interpret the original data and read about the theories.

Procedures - CABG and stenting - are still very important in 2 scenarios. First, patients who have just had an acute coronary syndrome, especially a small heart attack (which we call either NSTEMI or non-Q wave MI), clearly benefit from immediate intervention. Second, patients who have extensive disease (usually 2 or 3 vessels with severe narrowing) and problematic symptoms have their symptoms improved with interventions. Choosing an intervention must take into account the lesions, their location and availability of good artery past the obstruction. One must also consider current cardiac function (e.g., 3 vessel disease with a decreased ejection fraction has better results from surgery).

One should not go looking for disease to "repair" in asymptomatic patients. One might want to diagnose disease in patients with mild or equivocal symptoms - but not to "repair" the disease.

Regardless of whether patients do need a procedure, they need good medical management. I have written often about this issue. To reiterate:

We clearly know that coronary artery disease patients benefit from 4 drug classes

• Platelet inhibitors - aspirin, clopidogrel (in certain circumstances)
• Beta blockers
• ACE inhibitors or ARBs
• Statins

So the article and this editorial describe the current thinking of coronary artery plaques as fragile changing lesions. Understanding the dynamic nature of plaques gives us a broader understanding. This concept explains much current clinical trial and epidemiologic data. It drives current therapy.

Most important it should give hope to patients. As patients we can take some responsibility for our hearts. Exercise, weight control, and - when indicated - medications can modify coronary artery plaques, leading to regression and stabilization. Patients can often prevent coronary artery disease, but when they cannot (bad genetics especially), physicians can help greatly by prescribing the right drugs. Of course, the responsibility quickly reverts to the patient who then must take those medications.

Listening to philosophy tapes certainly gives me a different perspective on medicine. Currently I am listening to Will to Power: The Philosophy of Friedrich Nietzsche. This morning on the way to working out and then to work I was lietening in particular to: Lecture 11: Nietzsche on Truth and Interpretation. This lecture expands on the quote you see on the right of this blog: There are no facts, only interpretations. - Nietzsche .

As the lecturer expands on this discussion, I started to understand why yesterday's rant created such interest (8 comments by this morning). As I personally rate my rants, the number of comments provides me a good indicator of their effectiveness in stimulating thinking and interest.

Reading the comments, and then rereading Sydney's column, I realize that I am working from a different context. Nietzsche would argue (or at least the lecturer is arguing for him) that we only have interpretation in our attempts at truth. All interpretations depend on the context in which one views the data.

Our friend and frequent poster Bernie lives in a different contextual framework than I do. Thus, he views the same data but interprets it differently.

Now unlike many politically correctness advocates today, Nietzsche does not assume that all viewpoints have equal value (of course, he is judging from his own context). I believe that the bio-medical model is the superior model for judging medical data. (Bernie might disagree - but then I should not speak for Bernie).

As I read Sydney's column, she alludes to an important point. We must take all new data and put those data into our underlying context. What do we already know? Can we reconcile these new data with previous data?

I believe that the best way to interpret new data uses the principles of evidence based medicine. One should not discount