Many experts worry about chronic mercury poisoning. An advisory panel has published new recommendations, with specific reference to albacore tuna. U.S. Issues Guidelines on Eating of Some Tuna

The Food and Drug Administration and the Environmental Protection Agency will recommend Friday that pregnant women, nursing mothers and young children eat no more than six ounces of albacore tuna or about one meal's worth each week, administration officials said.

As the article states, the recommendations differ according to the type of tuna, with light tuna having less mercury.

The new guidelines will say that young children and women who are pregnant, nursing or planning to become pregnant can eat up to 12 ounces per week of light tuna, which has less mercury and accounts for about 13 percent of the nation's seafood consumption.

The agencies will continue recommending that those groups limit their intake of shark, swordfish, king mackerel and tilefish, which can also have high levels of mercury.

Colon cancer screening works, but many patients reject current screening tests for a variety of reasons. "Virtual" colonoscopy sounds like a nice alternative. The prep is just as unpleasant, but the risks are significantly less.

Gastroenterologists will support this technology, as it will increase their interventional colonoscopy business. Moreover, we do not have enough gastroenterologists to perform all the needed screening colonoscopies. Here is another study reporting on the diagnostic test performance of CT colonoscopy. CT Colonography Helpful in Cancer Screening

CT colonography compares well with conventional colonoscopy in detecting polyps with a diameter of at least 10 mm, New York-based researchers report in the March issue of Radiology. They concede that performance is lower with smaller lesions but point out that if patients undergo 5-year screening, "missing small lesions is likely to be clinically insignificant."

"The examination is well tolerated, does not require sedation and can be certainly used in patients who are unwilling to undergo conventional colonoscopy or in patients with underlying medical conditions that make conventional colonoscopy risky," lead investigator Dr. Michael Macari told Reuters Health.

Dr. Macari of Tisch Hospital, NYU Medical Center and colleagues also note that use of the evolving CT technique may increase public acceptance and thus increase the number of patients who undergo colon cancer screening.

To compare the results of the two screening approaches, the researchers studied 68 asymptomatic men who were deemed to be of average risk and were aged more than 50 years. They underwent CT colonography followed by colonoscopy on the same day.

A total of 98 polyps were found in 38 patients by colonoscopy. Of these, 21 (21.4%) were detected by CT. All 3 polyps of 10 mm or larger were uncovered by CT. However, this was true of only 11.5% (9 of 78) of those of 1 to 5 mm and 52.9% (9 of 17) of those of 6 to 9 mm in diameter.

Not an overwhelming study, but another piece of data in the continuing story.

There are no facts, only interpretations.
from Nietzsche's Nachlass, A. Danto translation.

Having been an expert witness on 2 occasions, I have chosen to no longer participate in the process. I have had colleagues who do this frequently. Being an expert witness is financially lucrative.

Because of the financial benefits we have a class of expert witnesses for hire. Reforming the "expert witness" system.

Medical malpractice civil trials often involve so-called expert witnesses in order to provide testimony on the current standards of medical practice and whether they were adhered to in a specific case or whether the actions of the physician where likely to have contributed to or directly caused injury to the patient. Such expert testimony is needed because of the insane way our justice system organizes civil trials.

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Therefore both the plaintiff and defendant use "expert witnesses" to provide testimony that supports one side or another and it is here where the problems start. The irony is that the same bias that the court wants to avoid in jurors by excluding peers of the same profession is accentuated in the form of expert witnesses who are paid for their testimony. This has created an entire industry of "expert witnesses for hire", many of whom have highly questionable credentials and are too willing to "stretch the truth" or even simply state their "expert opinion" without any evidence to base such an opinion.

Such testimony enables their side to win the case and this may, in turn, lead to the witness being hired for more cases by the same law firm (it is considered unethical to pay expert witnesses based on the outcome of the trial). An example of such abuse of the system involves Jetta Brown MD who was hired by trial lawyer Ramon Garcia to provide "expert testimony" in a lawsuit involving cardiothoracic surgery;

Go read his entire rant. He highlights a feature of the malpractice problem on which we rarely focus. And that feature is very important.

I rarely rant about osteoporosis, yet I probably should. Osteoporosis remains a major cause of morbidity and mortality, especially in post-menopausal women, but also in older men and especially those men and women who take corticosteroids.

Thus, this report is very encouraging. Osteoporosis Drug Found Safe to Take for 10 Years

For millions of women who have the bone-thinning disease osteoporosis, researchers are reporting that Fosamax, the drug most commonly used worldwide to improve bone density and prevent fractures, can be taken safely and effectively for 10 years.

About three million Americans now take the drug, most of them postmenopausal women with osteoporosis, according to its maker, Merck.

The new study, the longest clinical trial ever conducted in osteoporosis, found that Fosamax enabled postmenopausal women to maintain or increase their bone density through 10 years of treatment, with no apparent ill effects. The improved bone density persisted even after the drug was stopped and diminished only gradually.

The study is being published today in The New England Journal of Medicine.

Yes this is important good news. One always worries about long term effectiveness. This study documents the answer to an important clinical question.

Home BP Measurement More Useful Than Office Measurement

Home blood pressure (BP) measurement has better prognostic accuracy than office-based measurement, according to the results of a cohort study published in the March 17 issue of The Journal of the American Medical Association.

"BP measurement in clinicians' offices with a mercury sphygmomanometer has numerous drawbacks," write Guillaume Bobrie, MD, from the Hôpital Europeen Georges Pompidou in Paris, France, and colleagues from the SHEAF (Self-Measurement of Blood Pressure at Home in the Elderly: Assessment and Follow-up) study. "In contrast, the use of home BP measurement improves measurement precision and reproducibility."

In a European cohort of 4,939 elderly patients (48.9% men) being treated by general practitioners for hypertension, mean age was 70 ± 6.5 years, and mean follow-up was 3.2 ± 0.5 years. Uncontrolled hypertension was defined as at least 140/90 mm Hg for office BP and 135/85 mm Hg for home BP.

At the end of follow-up, at least one cardiovascular event (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, transient ischemic attack, hospitalization for angina or heart failure, angioplasty, or coronary artery bypass graft surgery) had occurred in 324 patients.

For BP self-measurement at home, the risk of a cardiovascular event increased by 17.2% (95% confidence interval [CI], 11.0% - 23.8%) for each 10-mm Hg increase in systolic BP, and by 11.7% (95% CI, 5.7% - 18.1%) for each 5-mm Hg increase in diastolic BP. However, the same magnitude of increase in BP observed using office measurement was not associated with any significant increase in the risk of a cardiovascular event.

This study does make sense. We all know about white coat hypertension.

When I was seeing private outpatients, I generally involved them in their hypertensive management by having them check their BP several times each week. We would use those measurements (taken at home, at a pharmacy or at the fire station) as the data that we used to adjust their BP meds.

I always believed that this method had two positive outcomes. First, it helped the patient understand that BP control was their job, not my job. I can only help patients; I cannot take their medications, do their exercise or modify their diet. Second, the measured BP gave more and accurate data on their BP average (which isolated office BP did not do).

This article reinforces my belief that the office BP can be spurious.

"Home BP measurement has a better prognostic accuracy than office BP measurement," the authors write. "BP should systematically be measured at home in patients receiving treatment for hypertension."

The Flip-Flop Files

When the National Academy of Sciences (NAS) recently concluded that one's sense of thirst -- not a set number of glasses of water -- should determine the amount of liquid to drink each day, this respected scientific group overturned yet another widely held piece of health advice.

Add that to a growing list of recommendations that recently have been tweaked, changed or outright discarded. In addition to ensuring full employment for health journalists, this trend has left many consumers baffled, annoyed and discouraged.

From the finding that hormone replacement therapy doesn't help prevent heart disease in post-menopausal women to the news that we need more of certain kinds of fat in our diets, new and contrary findings are reported regularly. And consumers who thought the conclusions of medical research were ironclad often have their confidence shaken.

"We just have to accept the fact that something that is considered correct now, in a year or two there may be findings that show up to say this really isn't necessary," said Munsey Wheby, president of the American College of Physicians and professor of medicine at the University of Virginia School of Medicine. "I'm sure the public feels, 'Can't scientists just get a set of information and stick to it?' But I don't know of any way around it."

Blame can be assigned many places. Researchers and institutions often over-promote the importance of their work. Journalists, suspecting that editors and audiences don't like shades of gray, tweak findings into black or white. Consumers baffled by all the hype in the health care marketplace demand simple, unambivalent advice to act on.

Even physicians can be frustrated by the flip-flops. After giving a lecture on new guidelines for vitamin supplements during pregnancy a number of years ago, Wheby fielded a question from a physician in the audience. "Why do they keep changing these things?" the doctor asked.

As experts note, medical research and practice have never been static.

"People want science to be definitive, but anyone who has explored science knows that it is an evolving process," said Neal Kohatsu, president-elect of the American College of Preventive Medicine and an associate professor of epidemiology at the University of Iowa's College of Public Health. "Rarely is there a single definitive study. It's a matter of looking at patterns over time and seeing the results come up by different investigators."

I have ranted concerning this general issue in the past. Science demands that we test and revise hypotheses. As a physician we must search for the best data and make decisions based on those data, understanding that we may change as new data appear.

Read the long article for an update on a wide variety of interesting dietary, exercise, and even some medication issues.

Around the Globe, Drug-Resistant TB Is Rampant. TB was once known as the white plague or consumption. Literature abounds with characters who died of this scourge.

During my medical career, we have had great drugs to treat TB. Most patients have a quick and successful cure. However, due to a variety of factors, we now must once again worry about TB.

"The true burden is unknown," said Dr. Mohamed Abdel Aziz, the organization's tuberculosis expert and leader of the study. "The more we survey, the more multi-drug-resistant TB we find."

Despite 10 years of effort, the organization has examined only about one-fifth of the world's cases. Some countries have been reluctant to participate, and setting up regional laboratories, a worldwide effort led by the Prince Leopold Institute of Tropical Medicine in Belgium, is expensive and time-consuming.

In South Africa, only 1.6 percent of the cases are drug-resistant, said Abigail B. Wright, another author of the study, but the country's overall tuberculosis rate is so high that that translates into 6,000 cases. In India, which has a major TB problem, a survey limited to Tamil Nadu state found a 3 percent resistance rate.

The report highlights the need for new tuberculosis drugs, said a spokeswoman for the Global Alliance for TB Drug Development.

"The last new drug was introduced in 1963," said the spokeswoman, Gwynne Oosterbaan. Because tuberculosis is a bacterium, virtually all antibiotics attack it. But drug companies rarely test their new antibiotics against it because they might be pressured to limit the drugs' use to that disease, costing them billions.

Tuberculosis is common in very poor countries with many AIDS cases, because weakened immune systems allow the bacteria to grow. But drug-resistant cases are more common in moderately poor countries where patients receive inadequate treatment.

Many cases were found in Kazakhstan, Uzbekistan, Estonia, Latvia, Lithuania and parts of Russia, as well as in two Chinese provinces, South Africa and Ecuador. On a smaller scale, a high rate of cases per capita was also found in Israel, presumably through immigration from countries of the former Soviet bloc, the report said.

The situation in former Soviet Union countries is particularly bad because of the abrupt collapse of the bloc's economy in the 1990's, said Dr. Peter Cegielski, leader of the international multi-drug-resistant TB team at the Centers for Disease Control and Prevention in Atlanta who conducts studies in Russia.

Shortages forced many patients to cut back to one or two drugs "and that's what leads to resistance," Dr. Cegielski said. Also, a number of prisoners with TB were released in amnesties, spreading the disease. In addition, said Dr. John Jereb, a C.D.C. epidemiologist, Soviet bloc countries used unusual treatments.

In the West and in poor countries following World Health Organization recommendations, all patients are supposed to get a cocktail of four "first-line" drugs: streptomycin, isoniazid, rifampicin and ethambutol. The standard therapy, "directly observed treatment, short-course," or D.O.T.S., requires that a family member, a nurse, or even a traditional healer watch each pill swallowed every day for six months.

The first-line drugs are cheap and have few side effects. Resistance develops when patients skip pills. But researchers also suspect resistance is high anywhere that the same drugs are sold over the counter, as they are in Southeast Asia.

One of my colleagues studies this problem. Most strains are susceptible to more expensive medications. Someone must find the money to treat these patients properly. We in the US do a particularly good job at treating TB through our public health departments. For this disease we have model programs.

As this epidemic spreads, it may well once again become a major health problem. Some would argue that it already is.

Congress is trying to take preemptive action against obesity-food lawsuits (like the poorly conceived McDonald's lawsuits. The trial lawyers are screaming foul! Fast food and fat lawsuits

But now that Congress is considering a ban on lawsuits blaming food manufacturers or sellers for making people fat, Mr. Banzhaf is eager to contradict himself. In a press release issued the day before the House approved the Personal Responsibility in Food Consumption Act by a 2-to-1 margin, he said the bill "is surely premature, because there has been only one obesity lawsuit, and it was dismissed by a federal judge."

Before Congress passes legislation like this, Mr. Banzhaf said, "there should be a real history of abuse which must be corrected, not orchestrated panic based upon one failed lawsuit and some quoted-out-of-context rhetoric." Having orchestrated the panic and provided the rhetoric, he knows whereof he speaks.

Huh?

This proposed law is necessary to prevent a series of lawsuits, spending the courts money unnessarily. But then the trial lawyers would like to argue about everything.

Perhaps this law, and the movement behind it will start to help us develop a real sense of personal responsibility. Our country needs more personal responsibility and less blame. But perhaps the existentialism speaking. But probably that is me speaking!

Is a high HDL really protective? This article discusses the controversy about HDL - Scientists Begin to Question Benefit of 'Good' Cholesterol

But now, some scientists say, new and continuing studies have called into question whether high levels of the good cholesterol are always good and, when they are beneficial, how much.

While some heart experts are not ready to change their treatment advice, others have concluded that H.D.L. should play at most a minor role in deciding whether to prescribe cholesterol-lowering drugs. In the meantime, doctors are calling researchers and asking what to do about patients with high H.D.L. levels, or what to do when their own H.D.L. levels are high, and patients are left with conflicting advice.

"There is so much confusion about this that it is unbelievable," said Dr. Steven Nissen, a cardiologist at the Cleveland Clinic.

Medical advances occur because we (physicians and scientists) willingly challenge current dogma. We never assume that we know truth, but just that we function on our current best approximation.

Fortunately, we generally make most decisions based on LDL levels anyway. HDL has functioned as a minor issue for most physicians. It may decrease from mino.

One of my loyal readers writes:

The one my school district offers doesn't work that way it all.
It's completely independent of the insurance plan.
At the end of the year, you forfeit anything you didn't claim.
We also can only take out 2500.00 a year.
The good news, is that it is pretax dollars.

And that is the same plan that I currently have.

The article is referring to the new law. This creates an entirely new option. I suspect that more companies and even the public sector will start to offer these new plans. The rollover benefit makes them a wonderful choice.

They do require insurance with larger deductibles - thus you are expected to pay for the initial costs from your HSAs. I like the idea. Reread the money management article about them to pick up the nuances.