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Monday, October 29, 2012

Exercise Benefits Brain In Middle Age

Exercise Benefits Brain In Middle Age

Gym-style exercise may improve not only general health in middle age, but also brain function, according to new research presented at the Canadian Cardiovascular Congress that is taking place in Toronto from 27 to 31 October.

The study, conducted by the Montreal Heart Institute (MHI), with the University of Montreal, and the Montreal Geriatric University Institute, found that cognitive ability improved significantly in a group of six middle-aged people with increased cardiovascular risk who followed a four-month program of high intensity interval training combined with resistance training.

High Intensity Interval Training

High Intensity Interval Training (HIIT) or High Intensity Training (HIT), is a form of exercise where you do a number of shorts bursts of intense and effortful activity alternating with short, less effortful work, such as a series of 30-second sprints with 30 seconds of walking or jogging in between.

It is not a new idea, but has come to prominence in recent years as more researchers have looked into and measured its health benefits. It came under the media spotlight in the UK in February 2012, when medical journalist Michael Mosley appeared in a TV program, where he tried a form of high intensity interval training and was pleasantly surprised by the results.

There are various forms of HIIT, depending on the intensity and duration of the effortful bursts, and fitness goals.

The Study

In this study the HIIT training the participants underwent alternated between short periods of low and high intensity aerobic exercise on stationary bicycles.

For four months, they had twice-weekly sessions of high intensity interval training combined with twice-weekly resistance training.

One of the researchers, Anil Nigam, chief of clinical care at MHI and also of the University of Montreal, says in a statement they worked with six middle-aged people who followed this program.

All six participants were overweight (their BMI was between 28 and 31) and had one or more cardiovascular risk factors. BMI is short for Body Mass Index, a measure of obesity that equals a person's weight in kilos divided by the square of their height in meters (BMI over 30 is considered obese, 25 to 30 is overweight).

Nigam explains the range of physical and mental measurements the participants underwent:

"Our participants underwent a battery of cognitive, biological and physiological tests before the program began in order to determine their cognitive functions, body composition, cardiovascular risk, brain oxygenation during exercise and maximal aerobic capacity."

The cognitive tests covered a range of memory and thinking exercises, such as remembering pairs of numbers and symbols.

Brain Oxygen

Using very sensitive instruments, the researchers also looked at how the participants' brains used oxygen while they exercised or did the mental tests. The instruments, which rely on near-infra red spectroscopy (NIRS), can detect minute changes in the volume and oxygenation of blood in the brain.

"Cognitive function, VO2max and brain oxygenation during exercise testing revealed that the participants' cognitive functions had greatly improved thanks to the exercise," says Nigam.

VO2max is a measure of the body's ability to take in, transport, and use oxygen during physical exertion. It also affects the body's ability to provide the brain with oxygen, which in turn impacts cognitive function.

At the end of the program, the participants also had smaller waists and less fat mass around the trunk of the body.

"We also found that their VO2max, insulin sensitivity had increased significantly, in tandem with their score on the cognitive tests and the oxygenation signals in the brain during exercise," says Nigam.

The study, which was funded by the ÉPIC Centre and Montreal Heart Institute Foundations, appears to support other recent research on the effect of exercise on the brain. Earlier this month, scientists at the University of Edinburgh reported that exercise may protect aging brains better than mental or leisure pursuits.

Saturday, October 27, 2012

Now You See the Stent, Now You Don't

Now You See the Stent, Now You Don't

MIAMI -- Some say bioabsorbable stents need more data, others say current drug-eluting stents are fine, but none of that mattered to the standing-room-only crowd who heard the latest research here on this novel technology.

The truth is that the current generation of drug-eluting stents have a good safety profile, with a very late stent thrombosis rate of about 0.5%.

But that was not the case when research began on bioabsorbable stents. Those were the days of first-generation drug-eluting stents, and even though DES revolutionized coronary revascularization, the advance came with two costs, Thomas Tu, MD, of Louisville Cardiology Group in Louisville, Ky., told MedPage Today at the Transcatheter Cardiovascular Therapeutics scientific symposium here.

"First, was the price, which was significantly higher than bare metal stents. Second, was the concern for longer duration of dual antiplatelet therapy," Tu said. "The fact that there were still questions about drug-eluting stents spurred further interest in perfecting this technique of opening blocked arteries."

Implanting a stent is an intentional injury to the coronary wall. It's a trade-off for unblocking the artery. Bare metal stents had no way of healing this acute injury, so, researchers developed stents with drugs that softened the acute intrusion.

This worked well for a while until it was evident that drug-eluting stents incurred a risk for late and very late stent thrombosis (after a year). Many pegged the source of the problem as the stent polymer, the drug carrier.

The next logical step was to develop a stent whose polymer would dissolve over time, leaving only a bare metal stent behind. In theory, this would solve the problem of the acute injury because the drug elutes early to help heal the endothelium and solve the problem of late stent thrombosis because the polymer disappears within 3 to 9 months.

How is this theory holding up under the research? Pretty good, discussant Antoine LaFant, MD, of the Hospital European Georges Pompidou in Paris, told MedPage Today.

"From this session, we can learn that bioabsorbable stents in humans have longer follow-up, from 3 to 5 years, which is quite reassuring in terms of the safety and efficacy," LaFant said.

Interestingly, LaFant and colleagues are pushing the envelope even further. They are developing a stent without a drug that disappears 3 months after implantation. "We take advantage of the positive remodeling resulting from the dismantling of the stent," he said. In preclinical studies, they have seen negative late loss at 9 months without any drugs. In July, they implanted the first human with this stent in a trial called ARTDIVA.

Patrick W. Serruys, MD, PhD, of Erasmus Medical Center in Rotterdam, The Netherlands, presented 5-year data from the all-comers LEADERS trial that compared two stents: the BioMatrix Flex, which has a biodegradable polymer that dissolves within 6 to 9 months and elutes biolimus (a semi-synthetic sirolimus analogue), and the Cypher Select, a first-generation sirolimus-eluting durable polymer stent that has been discontinued.

The BioMatrix Flex proved noninferior in the long-term to the Cypher in terms of major adverse cardiovascular events, and showed a significant reduction in very late stent thrombosis (0.66% versus 2.5%, P=0.003 for superiority).

Several bioabsorbable stents are approved in Europe, but none are FDA-approved.

Dual Antiplatelet Therapy

One of the theoretical advantages of the bioabsorbable stent is the potential to shorten the duration of dual antiplatelet therapy. But all studies of bioabsorbable stents so far have not veered from the recommended 12-month duration.

"How will we know if we can shorten therapy duration if no one will conduct a trial comparing 12-month duration with 6- or even 3-month duration," said Sigmund Silber, MD, of the Heart Center at the Isar in Munich, Germany, in an interview with MedPage Today.

Silber was involved in developing the original guidelines for dual antiplatelet therapy for the European Society of Cardiology. He and others looked at the data (no randomized trials), which suggested a threshold of 6 months would be optimal.

"The American's later became a little nervous and arbitrarily picked 1 year as the duration, but there are no data to support that," he said.

Interestingly, Silber and colleagues reviewed pooled data from the RESOLUTE global studies, which compared two second-generation drug-eluting stents with permanent polymers. About 1,000 of the 5,000 patients had interrupted or discontinued their dual antiplatelet therapy. Those who discontinued therapy after at least 1 or 3 months did not have any stent thrombosis at 1 year. But those who discontinued therapy in less than a month did have stent thrombosis within a year, he reported here at the TCT meeting.

"This was a very surprising finding, and although this post hoc analysis must be interpreted with caution, it does put the duration of dual antiplatelet therapy with a durable polymer in an interesting perspective," he said.

Silber is not convinced that the polymer is solely responsible for late stent thrombosis. He has yet to see convincing data. He also doubts he would use a bioabsorbable stent because the latest generation of drug-eluting stents are very good and without a shorter duration of antiplatelet therapy, he doesn't see an advantage.

Another concern is the price, which is about four to five times that of current drug-eluting stents. In Europe, these stents are not reimbursed, Silber said.

When, Not If

There seemed to be more people who believed that it's only a matter of time before drug-eluting stents with bioabsorbable polymers become routine in the cath lab. The evidence so far is good for relatively simple lesions, but these novel stents have not been tested in complex lesions, bifurcations, left main disease, heavily calcified lesions, total occlusions, and tortuous vessels, noted Ricardo Costa, MD, of the Cardiovascular Research Center in Sao Paulo, Brazil, in an interview with MedPage Today.

"I believe bioabsorbable stents have the potential to be incorporated in a significant proportion of PCI cases, but it will be very difficult to replace the low-profile modern drug-eluting stents we have today because they have very good results," he said.

Trying to convince interventional cardiologists to use bioabsorbable stents instead of those with a durable polymer may be challenging.

"I think saying that we have a tool that has the same advantages of the current stents but is a little better is probably not the best way to think about bioabsorbable technology," he said.

Tu suggested that bioabsorbable stents might find a home in other vascular beds, such as the superficial femoral artery, which is in constant motion and has resisted for the most part efforts from conventional stents.

He also said that it might be possible to use a completely bioabsorbable stent to deliver drugs to vulnerable plaque. The drug would heal the soft plaque and there would be no concomitant risk of having a permanent metallic stent in the body.


Atrial Fibrillation: Radiofrequency Catheter Ablation And Antiarrhythmic Drug Therapy Compared | CardioBrief

Atrial Fibrillation: Radiofrequency Catheter Ablation And Antiarrhythmic Drug Therapy Compared

A trial comparing radiofrequency catheter ablation (RFA) to antiarrhythmic drug therapy (AAD) as initial therapy for atrial fibrillation (AF) found no difference in the overall burden of AF between the groups. But the trial also turned up evidence supporting the use of RFA as an initial treatment strategy in some patients.

In a paper published in the New England Journal of Medicine, European investigators report on 294 patients with paroxysmal AF with no previous use of AADs who were randomized in the MANTRA-PAF (Medical Antiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation) trial. Patients– under 70 years of age and with no other major heart disease– were healthier than the general AF population.

The investigators found no significant differences in the cumulative burden of AF or the burden at  3, 6, 12, or 18 months. However, at 2 years the AF burden was significantly reduced in the RFA group compared with the AAD group (90th percentile of AF burden: 9% for RFA versus 18% for AAD, p=0.007). In addition, the percentage of patients with no AF and no symptomatic AF was higher in the RFA group than in the AAD group (85% vs. 71%, p=0.004; 93% vs. 84%, p=0.01, respectively). In the RFA group, there were three cases of cardiac tamponade in addition to one death after a procedure-related stroke. In the AAD group 36% of the patients received supplementary RFA.

The overall results, write the authors, "support the current guidelines recommending antiarrhythmic drugs as first-line treatment in most patients with paroxysmal atrial fibrillation." However, the positive findings for RFA, as well as the high number of crossovers from AAD to RFA, suggest that "a substantial minority of patients" treated with AAD "may eventually require ablation for adequate rhythm control."

In an accompanying editorial, William Stevenson and Christine Albert mention the "substantial procedural risks" associated with RFA and warn that the results should not be extrapolated to different patient populations, since the MANTRA-PAF population was younger and healthier than the general AF population. They express hope that the much larger CABANA (Catheter Ablation versus Anti-arrhythmic Drug Therapy for Atrial Fibrillation) trial will provide more definitive evidence about RFA. RFA, they conclude, is "a reasonable option for patients with symptomatic paroxysmal atrial fibrillation before therapy with an antiarrhythmic drug."

PFO Closure With Investigational Device Does Not Decrease Ischemic And Bleeding Events Compared To Medical Therapy

Cardiovascular / Cardiology News From Medical News Today PFO Closure With Investigational Device Does Not Decrease Ischemic And Bleeding Events Compared To Medical Therapy

Main Category: Cardiovascular / Cardiology
Article Date: 27 Oct 2012 - 0:00 PDT

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Results of the PC trial presented at TCT 2012

A clinical trial that compared catheter-based PFO closure using an investigational device found that there was no significant reduction in ischemic and bleeding events compared to standard medical therapy; stroke risk was non-significantly reduced with device therapy. The PC Trial was presented at the 24th annual Transcatheter Cardiovascular Therapeutics (TCT) scientific symposium. Sponsored by the Cardiovascular Research Foundation (CRF), TCT is the world's premier educational meeting specializing in interventional cardiovascular medicine.

A PFO (patent foramen ovale) is a hole between the left and right upper chambers (atria) of the heart that fails to close just after birth. Approximately one in four people grow up with a PFO. In some cases a blood clot may pass through the PFO and can potentially travel to the brain causing an ischemic stroke. It is estimated that PFO rates are three times higher in the population of patients with cryptogenic stroke, or stroke without an overt source.

The PC Trial compared the efficacy of the percutaneous closure of a PFO using the Amplatzer PFO Occluder with medical treatment in patients with cryptogenic stroke with peripheral embolism. Made of wire mesh, the investigational device is inserted into the PFO through a catheter to seal the passageway between the left and right atria.

Patients were randomized in 29 centers in Europe, Brazil, Canada, and Australia. Enrollment of 414 patients was completed in February 2009. The primary endpoint of the trial was a composite of death from any cause, non-fatal stroke, transient ischemic attack (TIA), and peripheral embolism.

For the primary composite endpoint (death from any cause, non-fatal stroke, TIA, and peripheral embolism) researchers found a relative risk reduction of 37 percent when using the investigational device; this reduction was not statistically significant. Results also indicated no significant reduction in ischemic and bleeding events in patients who underwent PFO closure compared to those who received medical therapy (2.9 percent versus 5.7 percent, HR 0.49, 95 percent CI 0.19 - 1.32, P=0.16). The relative risk reduction of stroke through use of the device was 80 percent with a number needed to treat (NNN) of 40, but this reduction was also not statistically significant.

"Percutaneous PFO closure with the investigational Amplatzer PFO Occluder device for secondary prevention of thromboembolism showed no significant reduction in ischemic and bleeding events compared with medical treatment in this trial," said study investigator Stephan Windecker, MD. Dr. Windecker is a Professor and Head of Interventional Cardiology at the Swiss Cardiovascular Center in Bern.

"However, the observed difference in stroke may be clinically relevant if confirmed in further studies," Dr. Windecker said.


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Sunday, October 21, 2012

Discovery Health "Advice for Beginning Runners"

Discovery Health "Advice for Beginning Runners"

When initiating a running program, some of us simply aspire to improve our health and fitness level, while others strive to complete a marathon. Whatever the goal, running is a cheap form of exercise that embodies all the general benefits of exercise as well as cardiovascular support. It can be done nearly anywhere at any time. 

There are a few dangers to jumping in and hitting the pavement. The body needs to have time to adapt to the demands of running. The impact to the lower leg with each step is 2-3 times your body weight. This means if you are a 150 pound runner who goes out for a 3 mile run, you will be subjecting your legs to about 400 pounds of force for approximately 2,500 repetitions. This is a big jump in demand if you have not been running.

Thankfully, your body adapts quite quickly with regular training. Over time, the bones and muscles of the legs become stronger and able to withstand the forces placed upon them. Starting out too fast, too often or too far are the most common errors. What follows is a guide to avoiding these missteps while still getting out on the road to becoming a runner.

One of the most important factors in starting a program is running form. Your posture should be upright with the arms relaxed. The body should be held still with the arms and legs moving freely. The feet should stay pointed straight ahead with the knees bending so that the heels reach the height of the knees when observed from the side or back. Hands can stay relaxed as though holding on to a potato chip without breaking it. The legs should generally feel relaxed and freely moving as though you were riding downhill on a bicycle while keeping up with the pedals.

Excessive strain or pounding can suggest that you are pushing the intensity and speed too much, which leads us to our first of the common errors. Starting out too fast means running at a pace for which your body is not ready. If you're not sure about whether you are prepared, start with walking. As walking speed and distance become more comfortable, add a little running; about 1 minute, separated by 5 minutes of walking. Initially, only run (or walk/run) every other day for the first couple of months to help your legs get adapted to your new activity.

Running too often limits the amount of time available for your body to adapt and recover. Your body actually gets stronger and more resistant to injury when it's resting. During your rest days and at night during sleep your body builds the areas you worked to a stronger level. Think of it like this: While you work out, you are providing your body the plans and instructions it needs. Then, while quiet and at rest, it does the actual work. If your body is not finished working by the time you go out for your next run, you will limit how well it can adapt. This can actually cause injury and, if extreme, will result in the symptoms of overtraining.

Running too far too early in your running program also causes the body to be under too much demand and stress. To prevent this, start out with a mileage that you can do in 20-30 minutes (when you can sustain a run for that amount of time without stopping to walk). Once a week, run no more than 1 mile farther than your longest run. Add 1 mile each week. Every 4-5 weeks cut your longest run mileage in half, then start back where you were the previous week adding 1 mile once a week. If your desire is to run farther multiple times a week, again add miles 1 at a time, and do it slowly. In general, increase your mileage by no more than 10 percent per week to allow your body to adapt sufficiently.

Starting a running program is really pretty simple. Sustaining one safely and patiently is the tough part. Follow our simple suggestions and try out our sample program for training for a marathon. Who knows, you might just become a runner yet!

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5 things that I want my patients to know

5 things that I want my patients to know

Today's healthcare consumer is constantly barraged with conflicting information. Does wine prevent or predispose to cancer? Should I eat certain foods or avoid them? Is this new medication going to hurt me or help me? Many issues are still controversial, but there are some things that have a large amount of evidence behind them.

1. Antibiotics will not help the common cold. Colds are caused by viruses, and antibiotics kill bacteria, which is a whole different type of organism. All of us have been through colds. We know that they are unpleasant–lots of sneezing, coughing, body aches, fever, feeling run down. All of us also know that colds will go away on their own. Some patients will swear that taking antibiotics will help them, but we know scientifically that this is not true; the cold is self-limited and was going to go away on its own anyway. Much better than taking a pill that doesn't work is to strengthen your immune system, and prevent the cold from happening in the first place. Get adequate sleep. Eat a healthy diet. If you do have a cold, drinking lots of fluids and taking Tylenol and ibuprofen is key to your recovery–not antibiotics.

2. A CT scan will not help a headache. Having a headache, just like catching a cold, is unpleasant. Your head throbs. You might feel that you can't concentrate and go about your daily activities. While there are potentially serious causes of headache, the vast majority of them are due to tension headache or migraine. These will go away with time. Again, over-the-counter medications like tylenol and ibuprofen can help, as can rest in a quiet, dark room and lots of fluids. A CT scan will only show what you DON'T have, and, in the vast majority of cases, will not help make your diagnosis–and certainly won't make you feel better.

3. Every test has potential side effects. Patients often ask their doctors for tests to figure out what's wrong; in the same way, doctors often rely on tests to save them time of speaking to patients to make the diagnosis. The problem is that tests can only tell you what you DON'T have, and not what you actually have. Studies have shown that actually sitting down with the patient and talking to her will much more likely yield the diagnosis than any test. And every test has potential side effects.  CT scans involve radiation, and studies have shown that each individual scan increases your lifetime risk of getting cancer. Some CTs and MRIs involve administering contrast dye that could cause kidney damage. Even the simple blood draw can lead to complications like infection and bruising. This is not to say that you should never get tests done; it's just a reminder that tests are not always the answer, and that you should make sure you know ahead of time what the risks and benefits are of every test.

4. Lifestyle changes make a huge difference. Study after study show that the single most important contributor to decreasing your risk of heart disease, for example, is your lifestyle. You can take pills to decrease your blood pressure, lower your cholesterol, and control your diabetes–but even better is to eat a healthy diet with low saturated fat and exercising. Similarly, the single biggest risk to health that is preventable is smoking. Within even a few months of stopping smoking, the risk of cancers and heart disease begins to decrease. Don't get me wrong: it's not easy. Working on your lifestyle requires far more investment in your time and energy than popping a pill. But it's the most effective way to really make a difference in your health.

5. Aspirin is one of few medications that's been definitively shown to help you. Big pharma would like us to believe that the newest and greatest drug is the best thing out there to prevent heart attack and stroke, but actually aspirin is one of very few medications that's proven its weight. It reduces the risk of hear attack and stroke, and some studies are demonstrating that it may even be preventative against cancer. People who experience chest pain get aspirin first, before they get anything else, because it is the one thing that helps them if they are already having a heart attack. Not everyone needs to take aspirin, and there are some for whom it may be harmful (all medications, just like all tests, have side effects), but this is one more reminder that the newest and greatest isn't always the best; sometimes it's the tried and true that you need.

Leana Wen is an emergency physician who blogs at The Doctor is Listening. She is the co-author of When Doctors Don't Listen: How to Prevent Misdiagnosis and Unnecessary Tests.  She can also be reached on Twitter @drleanawen

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Saturday, October 20, 2012

Chocolate And Nobel Prizes Linked In Study

CardioBrief Chocolate And Nobel Prizes Linked In Study

You don't have to be a genius to like chocolate, but geniuses are more likely to eat lots of chocolate, at least according to a new paper published in the august New England Journal of Medicine. Franz Messerli reports a highly significant correlation between a nation's per capita chocolate consumption and the rate at which its citizens win Nobel Prizes. Building on research raising the possibility that the flavanols in chocolate may enhance cognitive performance, Messerli "wondered whether there would be a correlation between a country's level of chocolate consumption and its population's cognitive function." Using More…


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Monday, October 15, 2012

Sitting For Long Periods Raises Your Risk Of Diabetes, Heart Disease

Sitting For Long Periods Raises Your Risk Of Diabetes, Heart Disease

Featured Article
Academic Journal
Main Category: Diabetes
Also Included In: Sports Medicine / Fitness;  Heart Disease;  Obesity / Weight Loss / Fitness
Article Date: 15 Oct 2012 - 4:00 PDT

Sitting around for long periods raises the risk of developing type 2 diabetes, heart disease and premature death, even for people who have the amount of daily physical activity recommended by health professionals.

These were the conclusions of a large piece of research covering nearly 800,000 participants published in Diabetologia this week.

Emma Wilmot of the University of Leicester in the UK, and colleagues, pooled the results of 18 studies covering a total of 794,577 participants, and found people who sit for long periods have twice the risk of developing type 2 diabetes, heart disease and premature death compared to people who do not.

In a press statement issued over the weekend, they say their analysis found these links were still strong when they took into account the amount of moderate to vigorous physical activity people underwent; even those who met typical physical activity guidelines may still be harming their health by sitting around for long periods the rest of the time.

"The average adult spends 50-70% of their time sitting so the findings of this study have far reaching implications," says Wilmot, a a Clinical Research Fellow in Diabetes and Endocrinology working at the Leicester Diabetes Centre, in Leicester General Hospital.

"By simply limiting the time that we spend sitting, we may be able to reduce our risk of diabetes, heart disease and death," she urges.

Their analysis revealed that the most consistent links were between sitting and diabetes. Wilmot says this finding is particularly important for those groups who already have a higher risk for type 2 diabetes, such as people of South Asian descent, or with a family history of the disease.

The study is not the first to highlight the health risks of sitting for prolonged periods. For example earlier this year, researchers at Leicester's departments of health sciences and cardiovascular science revealed how they found women who sit for most of the day have a greater risk for developing the metabolic symptoms that precede type 2 diabetes.

Another study found that interrupting prolonged periods of sitting with regular, two-minute breaks of light or moderate intensity activity like walking helped overweight people keep glucose and insulin levels under control.

This latest review also involved researchers from Loughborough University, where co-researcher Stuart Biddle is professor of physical activity and health. He suggests a number of ways people can reduce their sitting time, "such as breaking up long periods at the computer at work by placing our laptop on a filing cabinet."

Another co-researcher, Melanie Davies, professor of diabetes medicine at Leicester, is a director of the National Institute for Health Research's Leicester-Loughborough Diet, Lifestyle and Physical Activity Biomedical Research Unit, and is also honorary consultant at University Hospitals of Leicester. She says the paper also has an important message for health care professionals:

"... namely that being sedentary is common and dangerous for our long term health, particularly for diabetes and cardiovascular disease, and that this link appears to be over and above other lifestyle factors such as our diet and physical activity."

Written by Catharine Paddock PhD
Copyright: Medical News Today
Not to be reproduced without permission of Medical News Today

Visit our diabetes section for the latest news on this subject.

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Friday, October 12, 2012

Statins Decrease Glaucoma Risk in Those With Hyperlipidemia (mobile format)

Statins Decrease Glaucoma Risk in Those With Hyperlipidemia

October 10, 2012 — In patients with hyperlipidemia, statin use for 1 year decreased the hazard of developing open-angle glaucoma (OAG) by 5%, and use for 2 years decreased it by 9%, according to a retrospective, longitudinal cohort analysis. Individuals who used statins also had a decreased risk of progressing from suspected glaucoma to OAG and needing intraocular pressure–lowering medications.

Joshua D. Stein, MD, an assistant professor in the Department of Ophthalmology and Visual Sciences at the University of Michigan in Ann Arbor and colleagues, published their findings in the October issue of Ophthalmology.

This study was prompted by findings from an earlier study in which they evaluated whether patients with components of metabolic syndrome had an increased risk for OAG, said Dr. Stein.

"We found that, unlike diabetes and high blood pressure (each of which was associated with an elevated risk for OAG), the presence of hyperlipidemia was associated with a reduced risk for glaucoma. That result led us to wonder whether it might in fact be the medications used to treat hyperlipidemia (primarily agents from the class of drugs called statins), rather than the condition of hyperlipidemia itself, that could protect against the onset of OAG," Dr. Stein explained.

To find out, they analyzed data for eye-related claims obtained from detailed records of all enrollees in a managed care network with members located across the United States.

Of the 524,109 enrollees with hyperlipidemia, 316,182 (60.3%) had 1 statin prescription, 20,776 (4%) were prescribed nonstatin cholesterol-lowering medications only, and 187,151 (35.7%) were prescribed no cholesterol-lowering drug during follow-up.

A total of 92,955 (29.4%) statin users also filled 1 prescription for a nonstatin cholesterol-lowering drug.

Of the 241,711 patients eligible for the incident OAG analysis 10,266 (4.3%) patients were given at least 1 incident diagnosis of OAG while in the medical plan.

With every additional month of statin use the hazard of developing OAG decreased 0.3% (adjusted hazard ratio [HR], 0.997; 95% confidence interval [CI], 0.994 - 0.999; P < .0056) after adjustments for sociodemographic factors, and medical and ocular comorbid conditions.

Individuals who took statins for 1 year during the 2 prior years had a 4% decreased hazard (adjusted HR, 0.960; 95% CI, 0.933 - 0.988) of OAG relative to those who took no statins in the 2 prior years, if all other characteristics were alike.

Similarly, those who used statins continuously for 2 years had an 8% decreased risk (adjusted HR, 0.922; 95% CI, 0.870 - 0.976) of OAG relative to patients who used no statins during the prior 2 years.

No association was found between use of nonstatin cholesterol-lowering drugs and OAG development (P = .12).

After individuals given a diagnosis of OAG during their first 2 years of enrollment were excluded, 6934 individuals (14.0%) developed OAG among the 49,628 patients in whom suspected glaucoma was diagnosed during the look-back period.

After adjustment for confounders, the risk of progressing from suspected glaucoma to OAG decreased 0.4% (adjusted HR, 0.996; 95% CI, 0.993 - 0.999; P = .0062) for every additional month of statin use.

Individuals who used statins for 1 year during the prior 2 years had a 5% decreased risk (adjusted HR, 0.952; 95% CI, 0.920 - 0.986) of progressing from suspected glaucoma to OAG relative to patients with suspected glaucoma who used no statins in the prior 2 years.

Individuals who used statins continuously for 2 years had a 9% decreased hazard (adjusted HR, 0.907; 95% CI, 0.846 - 0.973) of OAG relative to those who used no statins in the prior 2 years.

There was no difference in the hazard in patients who used nonstatin cholesterol-lowering drugs (P = .077).

The risk for receiving a glaucoma medication prescription decreased 0.4% (adjusted HR, 0.996; 95% CI, 0.993 - 0.998; P = .0002) for every additional month of statin use after adjustment for confounders.

Use of statins for 1 year during the prior 2 years resulted in a 5% decreased risk (adjusted HR, 0.950; 95% CI, 0.924 - 0.976) of needing an intraocular pressure–lowering drug relative to those who used no statins in the prior 2 years.

Individuals who used stains continuously for 2 years had a 10% decreased risk (adjusted HR, 0.902; 95% CI, 0.854 - 0.953) of needing a pressure-lowering drug relative to those who used no statins in the prior 2 years.

Individuals who used nonstatin cholesterol-lowering medications had a 0.6% (adjusted HR, 0.994; 95% CI, 0.990 - 0.998; P = .0017) hazard per month for being prescribed a glaucoma medication.

Use of a nonstatin cholesterol-lowering medication for 1 year during the prior 2 years resulted in a 7% decreased risk (adjusted HR, 0.928; 95% CI, 0.886 - 0.972) of being prescribed glaucoma medications. Use of a nonstatin cholesterol-lowering medication for 2 years was associated with a 14% (adjusted HR, 0.862; 95% CI, 0.785 - 0.946) decreased risk of receiving a prescription for a glaucoma medication.

A total of 8236 individuals with an incident OAG diagnosis had no glaucoma surgical intervention coded before that diagnosis. Of those patients, 1009 (12.3%) later required laser or incisional glaucoma surgery while enrolled in the plan.

The risk of an enrollee going on to require laser or incisional glaucoma surgery was not significantly different (adjusted HR, 1.002; 95% CI, 0.994 -1.010) with each additional month of statin use (P = .68) after adjustment for confounders. Findings were similar for nonstatin cholesterol-lowering medications (adjusted HR, 0.992; 95% CI, 0.978 - 1.006; P = .27).

New Treatment Pathway?

"This is a very exciting new report suggesting that there may be an entirely new pathway for treating or preventing glaucoma," said Joel Schuman, MD, a clinical correspondent for the American Academy of Ophthalmology. Dr. Schuman, who was not involved in the study, is a professor at the Eye & Ear Foundation, chairman of ophthalmology at the University of Pittsburgh School of Medicine, director of the UPMC Eye Center, and interim director of the Fox Center for Vision Restoration in Pittsburgh, Pennsylvania.

Encouraged by his team's findings, Dr. Stein told Medscape Medical News, "Although physicians already have various effective treatment options...the discovery of a lower-cost option with relatively few side effects could be enormously useful. Also, because strict adherence to prescribed treatment regimens involving topical glaucoma medications can be challenging for many patients, the prospect of a potential alternative taken orally could ultimately mean the difference between sight loss and preserved vision for countless adults."

He said the next step should be a "randomized controlled trial to test the potential efficacy of statin drugs to prevent glaucoma or halt disease progression."

However, Dr. Schuman cautioned that these findings may not apply to everyone. "It is important to remember that subjects studied were treated with statins for hyperlipidemia. While this retrospective study sets the stage for a larger-scale prospective trial to assess the benefit of statin treatment in people predisposed to or with glaucoma, it does not mean that all such people should be treated with statins to prevent or manage the disease."

This study was supported by the National Eye Institute K23 Mentored Clinician Scientist Award; American Glaucoma Society Clinician Scientist Grant, Blue Cross Blue Shield of Michigan Foundation, Research to Prevent Blindness, and a National Eye Institute Core Grant. The authors and Dr. Schuman have disclosed no relevant financial relationships.

Ophthalmology. 2012;119:2074-2081. Full text

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Thursday, October 11, 2012

Troubled Sleepers at Risk for Soft Plaque

Troubled Sleepers at Risk for Soft Plaque

By Chris Kaiser, Cardiology Editor, MedPage Today
Published: October 11, 2012
Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Obstructive sleep apnea has been linked with cardiovascular disease, but it also may be linked with the deadliest type of coronary artery plaque, a small study suggests.

Of patients with obstructive sleep apnea (OSA), 63% had noncalcified or mixed plaques compared with 16% of those without OSA (P<0.0001), according to Sunil Sharma, MD, of East Carolina University in Greenville, N.C., and colleagues.

The unadjusted odds ratio was 9.3 (95% CI 3.0 to 28.4), but even when researchers adjusted for other risk factors, the association of OSA with soft plaque "remained strong" (OR 7.0, 95% CI 1.9 to 26.5, P<0.05), they reported in the study published online in Clinical Cardiology.

"The broad confidence interval was most likely due to small sample size, but we cannot rule out the effect of unobserved confounding factors," researchers noted.

However, Sharma told MedPage Today that the investigators "felt comfortable" with their unique finding regarding more soft plaque in those with OSA because of similar findings linking hard, calcified plaques with OSA.

"We know that hard plaques don't cause acute events. So we wanted to see if those with sleep-disordered breathing had a higher prevalence of soft plaque," Sharma said.

Despite the known connection between sleep apnea and cardiovascular disease, data are limited on whether OSA "causes or accelerates the process of atherosclerosis and plaque formations."

And data are similarly lacking on exactly what type of plaque is most prevalent in those with OSA.

To categorize plaque type, researchers retrospectively reviewed the cardiac CT images of 81 patients who were part of a larger radiology study at the Medical University of South Carolina in Charleston involving emergency room patients with acute chest pain.

All patients had undergone a gold-standard polysomnography test within the prior 3 years of the CT scan, and 51 had OSA.

Baseline characteristics were similar between patients with and without OSA, except in three categories: age (60 versus 54, P=0.05), race (75% white versus 53%, P=0.04), and past smoking (62% versus 39%, P=0.004).

Besides there being an overall strong association of OSA with noncalcified/mixed plaques, the severity of OSA was linearly associated with soft plaques, but the confidence intervals were wide.

Those with an apnea-hypopnea index (AHI) of between 10 and 20 (mild OSA) had an odds ratio of 3.2 (95% CI 0.2 to 43.7) compared with 14.2 (95% CI 1.3 to 158.5) for those with an AHI greater than 20 (moderate to severe OSA). These odds were adjusted for age, sex, race, smoking history, and hypercholesterolemia.

This pattern repeated itself when researchers evaluated patients for multivessel disease and stenosis severity (both P<0.05). Again, however, the confidence intervals were very wide.

Significantly more patients with OSA had multiple coronary artery involvement (85.7% versus 34.5%), which correlated linearly with the severity of apnea (ORs 9.6 for mild OSA and 42.1 for moderate to severe OSA).

Also, more patients with OSA had significantly higher severity of stenosis (22.5% versus 6%), and the severity of artery stenosis correlated with the severity of OSA (7.7% with multivessel disease had mild OSA compared with 24% with severe OSA).

"These findings tend to suggest that sleep-disordered breathing accelerates the process of atherosclerosis," Sharma told MedPage Today.

However, the results should be confirmed in larger, randomized studies, he said.

There is speculation that OSA might actually influence the duration of soft plaques, meaning that they stay in a soft stage longer than usual, Sharma said. "But this is mere speculation at this point," he said.

The next steps include determining what impact the higher prevalence of soft plaques has on outcomes and evaluating whether the use of continuous positive airway pressure (CPAP) therapy could make these vulnerable plaques more stable.

There is evidence from carotid ultrasound studies that CPAP therapy is associated with a reduced level of plaque, Sharma said.

Limitations of the current study include its retrospective nature, small number of patients, potential referral bias, and not having data on compliance with CPAP therapy.

The authors reported they have no conflicts of interest.

From the American Heart Association:


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Wednesday, October 10, 2012

Terrific Idea

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Fast walking and jogging halve development of heart disease and stroke risk factors, research indicates

Fast Walking and Jogging Halve Development of Heart Disease and Stroke Risk Factors, Research Indicates

ScienceDaily (Oct. 8, 2012) — Daily activities, such as fast walking and jogging, can curb the development of risk factors for heart disease and stroke by as much as 50 per cent, whereas an hour's daily walk makes little difference, indicates research published in the online journal BMJ Open.

The findings indicate that it is the intensity, rather than the duration, of exercise that counts in combating the impact of metabolic syndrome -- a combination of factors, including midriff bulge, high blood pressure, insulin resistance, higher than normal levels of blood glucose and abnormal blood fat levels -- say the authors.

Genes, diet, and lack of exercise are thought to be implicated in the development of the syndrome, which is conducive to inflammation and blood thickening.

The authors base their findings on more than 10,000 Danish adults, between the ages of 21 and 98, who were initially assessed in 1991-94 and then monitored for up to 10 years. All the participants were quizzed on the amount of physical activity they did, which was categorised according to intensity and duration.

At the initial assessment, around one in five (20.7%) women and just over one in four (27.3%) men had metabolic syndrome. Prevalence was closely linked to physical activity level.

Among the women, almost one in three of those who had a sedentary lifestyle had the syndrome whereas only one in 10 of those who were very physically active had it. Among men, the equivalent proportions were just under 37% and just under 14%

Of the remaining 6,088 participants without metabolic syndrome, just under two thirds (3,992) completed the fourth and final survey and assessment, by which point one in seven (15.4%; 585) had developed it.

Again, the prevalence was higher among those leading a sedentary lifestyle, with almost one in five (19.4%) affected compared with around one in nine (11.8%) of those who were very physically active.

It was not only the amount of exercise, but also the intensity which helped curb the likelihood of developing the syndrome.

After taking account of factors likely to influence the results, fast walking speed halved the risk, while jogging cut the risk by 40 per cent. But going for an hour's walk every day made no difference.

"Our results confirm the role of physical activity in reducing [metabolic syndrome] risk and suggest that intensity rather than volume of physical activity is important," conclude the authors.

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The above story is reprinted from materials provided by BMJ-British Medical Journal.

Note: Materials may be edited for content and length. For further information, please contact the source cited above.

Journal Reference:

  1. A. H. Laursen, O. P. Kristiansen, J. L. Marott, P. Schnohr, E. Prescott. Intensity versus duration of physical activity: implications for the metabolic syndrome. A prospective cohort study. BMJ Open, 2012; 2 (5): e001711 DOI: 10.1136/bmjopen-2012-001711

Note: If no author is given, the source is cited instead.

Disclaimer: This article is not intended to provide medical advice, diagnosis or treatment. Views expressed here do not necessarily reflect those of ScienceDaily or its staff.

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Monday, October 8, 2012

Sleep apnea plays dual role in stroke

Sleep Apnea Plays Dual Role in Stroke

ScienceDaily (Oct. 2, 2012) — Improvements to the diagnosis and screening of sleep apnea are critical to stroke prevention, according to new stroke care guidelines released October 2 at the Canadian Stroke Congress.

Obstructive sleep apnea, a disorder where the flow of air to the brain pauses or decreases during sleep, is both a risk factor for stroke and a complication following stroke, according to the Canadian Best Practice Recommendations for Stroke Care.

Among the general population sleep apnea increases the likelihood of having a stroke, even after controlling for other stroke risk factors, such as high blood pressure and diabetes, researchers say.

At absolute minimum, four per cent of men and two per cent of women have serious sleep apnea, says Dr. Brian Murray, an associate professor of neurology and sleep medicine at the University of Toronto. Dr. Murray adds that clinically significant forms of the disorder affect more than 10 per cent of the population.

"There are ways to prevent sleep apnea from occurring," says Dr. Murray. "Keep your body weight low as obesity is a major contributor to sleep apnea; avoid medications and substances that relax the airways and cause snoring, such as sedatives and alcohol; and sleeping on your side can minimize sleep disordered breathing."

Signs of sleep apnea include significant snoring, pauses in breathing during sleep and daytime fatigue despite adequate sleep time. If any of these symptoms are present, says Dr. Murray, you should be evaluated by your doctor to determine next steps.

Obstructive sleep apnea is common after stroke. According to the updated best practice recommendations, at least 60 per cent of stroke patients experience sleep apnea. The new recommendations call for more screening of stroke patients who say they experience snoring, fragmented sleep or fatigue. Although, in many cases with stroke patients, daytime fatigue does not appear as a symptom, says Dr. Murray.

It is crucial for stroke patients to be screened for sleep apnea because untreated sleep apnea increases the chances of a second stroke and small studies have found that stroke patients with sleep apnea tended to have worse rehabilitation outcomes, says Dr. Murray.

The best practices also describe "higher rates of mortality and other complications in patients with stroke and untreated obstructive sleep apnea."

"This innovative Canadian research continues to show that there is more to learn about rehabilitation and recovery following stroke," says Ian Joiner, director of stroke for the Heart and Stroke Foundation. "Reflecting these advances in tools such as the Best Practices Recommendations for Stroke Care will help improve outcomes for Canadians."

The new recommendations are the fourth update to the Canadian Best Practice Recommendations for Stroke Care and this is the first time the recommendations have included a section on sleep apnea. The best practices were first released in 2006 to improve stroke care for Canadians living with stroke and future stroke patients. They are updated every two years.

"The new recommendations take stroke care a step further," says Dr. Michael Hill, Canadian Stroke Congress Co-Chair. "Stroke care is not only about giving the best possible treatment to patients. It is also about preventing new and recurrent strokes."

The Canadian Stroke Congress is a joint initiative of the Canadian Stroke Network, Heart and Stroke Foundation of Canada and the Canadian Stroke Consortium.

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Note: Materials may be edited for content and length. For further information, please contact the source cited above.

Note: If no author is given, the source is cited instead.

Disclaimer: This article is not intended to provide medical advice, diagnosis or treatment. Views expressed here do not necessarily reflect those of ScienceDaily or its staff.

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Many drugs are just fine years after they 'expire,' study finds - latimes.com

Many drugs are just fine years after they 'expire,' study finds

Chances are, your medicine cabinet contains some pills that are past their expiration date. You might even have some pain relievers, some cough syrup or some sleeping pills that were purchased back when Richard Nixon was in the White House. But you can't seem to throw them away because you suspect they might still be OK to take.

If you've wondered whether medicines really do need to be tossed after their expiration date, you're got some company at the California Poison Control System, UC San Francisco and UC Irvine. Researchers from those institutions decided to satisfy their curiosity by testing the effectiveness of eight drugs that had been sitting around, unopened, in pharmacies for years after they had supposedly gone bad.

These drugs were not just a few years past their prime, these medications were a full 28 to 40 years past their official expiration dates.

The eight drugs contained a total of 15 active ingredients. The researchers couldn't find a standard test for one of them (homatropine), so they focused their analysis on the other 14.

The tablets and capsules were dissolved and subjected to chemical analysis using a mass spectrometer. That revealed how much of the active ingredients remained in the pills.

Out of the 14 active ingredients, 12 were still at high enough concentration – 90% of the amount stated on the label – to qualify as having "acceptable potency," the researchers found. These included:

Acetaminophen (the pain reliever in Tylenol)

Codeine (an opiate that treats pain and coughs)

Hydrocodone (an opiate used to treat moderate to severe pain)

Phenacetin (an analgesic that's not used much anymore)

Caffeine (a stimulant)

Chlorpheniramine (an antihistamine used to treat colds and allergies)

Pentobarbital (a short-acting barbiturate)

Butalbital (a barbiturate that lasts for an intermediate period of time)

Secobarbital (a barbituate used to treat insomnia)

Phenobarbital (a barbiturate that controls seizures and relieves anxiety)

Meprobamate (a tranquilizer to treat anxiety)

Methaqualone (a sedative and muscle relaxant known by the brand name Quaaludes)

The only active ingredients that missed that cutoff were aspirin and the stimulant amphetamine.

The expiration date on a drug is usually one to five years after it was manufactured. But those dates are often set arbitrarily, since the Food and Drug Administration doesn't require pharmaceutical makers to test how long the active ingredients will last, the researchers wrote.

They noted that the Shelf-Life Extension Program allows drugs in federal stockpiles to be retained for up to 278 months after their stated expiration date if tests show they are still potent. But some of the ingredients tested in this study remained good for 480 months – so far.

The research team's obvious conclusion? "Our results support the effectiveness of broadly extending expiration dates for many drugs," they wrote.

"The most important implication of our study involves the potential cost savings resulting from lengthier product expiration dating," they added. "Given that Americans currently spend more than $300 billion annually on prescription medications, extending drug expiration dates could yield enormous health care expenditure savings."

The analysis was published online Monday by Archives of Internal Medicine. The full report is behind a paywall, but you can can read the first page here.

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The Deadly Threat of Silent Heart Attacks - NYTimes.com

The Deadly Threat of Silent Heart Attacks

For more than six months, Harriett Cooke had been uncommonly tired, panting when she walked her sixth grade science class to the cafeteria and struggling to keep her eyes open when she drove home at night.

One day, during a class trip outside the school, she just couldn't go on. "I sat there on the side, I put my head down on the table, and I knew I shouldn't be feeling like this," said Ms. Cooke, 67, who lives in Durham, N.C.

Making excuses, she left and stopped at her doctor's office, where staff ordered an electrocardiogram (EKG). The test showed that Ms. Cooke had suffered a so-called "silent heart attack" at some indeterminate point, perhaps months earlier.

Few people know about this type of heart attack, characterized by a lack of recognizable symptoms. Yet silent heart attacks are even more common in older adults than heart attacks that immediately come to the attention of doctors and patients, according to a recent study in The Journal of the American Medical Association.

What's more, they're equally deadly.

The research underscores the importance of paying attention to lingering, hard-to-pin-down symptoms in older adults, experts say. Many elderly men and women tend to dismiss these; caregivers shouldn't let that happen.

The JAMA report is based on data from 936 men and women ages 67 to 93 from Iceland who agreed to undergo EKGs and magnetic resonance imaging exams to detect whether heart attacks had occurred. EKGs assess the heart's electrical activity, while M.R.I.'s look at its mechanical pumping activity.

So-called "recognized" heart attacks were identified when signs of heart damage were evident, and the patient's medical record indicated that medical attention had been sought and a diagnosis rendered. "Silent" heart attacks were also signified by heart damage, but in those cases evidence from medical records was lacking.

When results were tallied, silent heart attacks were twice as common (22 percent) among older patients as recognized heart attacks (10 percent). Five years after tests were administered, death rates for patients with both recognized and silent heart attacks were 23 percent, almost double the 12 percent death rate for older adults who'd never experienced a myocardial infarction, the technical name for this medical event.

Recognized heart attacks may be more serious in the short run, but silent heart attacks are equally dangerous in the long run because they don't receive medical attention, said Dr. Andrew E. Arai, the lead author and chief of the cardiovascular and pulmonary branch of division of intramural research at the U.S. National Heart, Lung and Blood Institute.

Indeed, seniors who had the silent version were less likely to get treatments for coronary artery disease — aspirin, beta blockers, and cholesterol-lowering statins. Yet tests documented they had higher-than-average risk factors: elevated blood pressure, high cholesterol, hardening of the arteries, and evidence of plaque buildup in blood vessels.

Results from Iceland may not be fully generalizable to the United States since more people smoke in Iceland, and there's greater diversity in the population here. But a key takeaway message is that heart attacks aren't always easy to detect, especially in older people.

"Not everyone has classic symptoms — chest pain, maybe radiating to the arm, nausea, sweating, shortness of breath," Dr. Arai said.

"In reality, many patients, have much less clear cut symptoms," he continued. "They may think it's a bad case of indigestion or the flu, or this may even occur during their sleep and they won't realize that anything happened."

If you're an older person and you've been feeling seriously unwell for a while, "go see your doctor, don't blow it off," Dr. Arai said.

That's not an invitation for people to run out and demand M.R.I.'s of the heart if they've been feeling flulike for several weeks. Although M.R.I.'s identified more silent heart attacks than EKGs in the JAMA report, these tests are expensive, not widely available, and stress echocardiograms, nuclear stress tests, and computerized tomography (CT) coronary angiograms are good alternatives, said Dr. Michael Shen, section head of cardiac imaging at the Cleveland Clinic in Florida.

Tests should be based on the patient's family history, personal history, symptoms like shortness of breath or tightness in the chest, and risk factors like cholesterol levels, high blood pressure, smoking and diabetes, Dr. Shen said.

In the JAMA study, 26 percent of patients with diabetes (266 altogether) had silent heart attacks, compared with 11 percent who had clinically recognized heart attacks.

"We don't really understand what causes one person to have chest pain and another person not to have chest pain," said Dr. LeRoy E. Rabbani, director of cardiac intensive care and the cardiac inpatient service at NewYork-Presbyterian Hospital/Columbia University Medical Center in New York. But diabetics, who are prone to nerve damage known as neuropathy, "may have impaired sensation that extends to chest wall."

To illustrate the point, Dr. Rabbani tells of an elderly patient who had undergone coronary artery bypass surgery and had stents implanted in his arteries to prop them open. Each time his heart gave him trouble over a period of a dozen years, he had felt chest pain.

But one day, after developing diabetes in his 80s, this patient felt a little dizzy, noticed a nose bleed and fainted after arriving at his ear nose and throat doctor's office. In the emergency room, tests showed that he had had a heart attack, with no symptoms this time, six hours before. "Even in a given individual, things can change," Dr. Rabbani said.

There's no opportunity to restore heart muscle damaged in a silent heart attack, but there is opportunity to intervene to prevent a second heart attack or heart failure.

"One has to look at (a silent heart attack) as a potential marker for coronary atherosclerosis and take a more detailed look to see if risk factors are being treated adequately," said Dr. Christopher O'Connor, chief of cardiology at Duke University School of Medicine.

If damage is relatively mild, "there are a whole host of medications we can use to prevent the occurrence of a second event," he said. If damage is more significant, bypass surgery, stents, and even devices like implantable defibrillators may be warranted.

Afterward, doctors monitor patients more frequently and "pay much more attention to ambiguous symptoms like prolonged fatigue, confusion or shortness of breath," Dr. O'Connor continued. "Before, we thought these silent events were less important. Now, we realize they're equally important as symptomatic heart attacks and deserving of careful follow-up."

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Thursday, October 4, 2012

A Possible Price to Pay if Doctors Spurn Insurance - NYTimes.com

When Doctors Stop Taking Insurance

Tim Bower

Private health insurance used to be the ticket to a doctor's appointment. But that's no longer the case in some affluent metropolitan enclaves, where many physicians no longer accept insurance and require upfront payment from patients — cash, checks and credit cards accepted.

On Manhattan's Upper East Side, it's not unusual for a pregnant woman to pay $13,000 out of pocket in advance for childbirth and prenatal care to a physician who does not participate in any health plan. Some gynecologists are charging $650 for an annual checkup. And for pediatricians who shun insurance, parents on the Upper East Side are shelling out $150 to $250 whenever a child falls or runs a high fever.

Efforts by insurers to rein in health care costs by holding down physician fees — especially for primary care doctors, who play a critical role in health care though they are among the lowest paid doctors — appear to be accelerating the trend, and some patients say it's getting harder to find an in-network physician.

Orlene Paxson, 33, a stay-at-home mom on Manhattan's Upper East Side, was unable to find an obstetrician she liked who would accept her insurance. Many were not accepting new patients, and one highly recommended doctor did not return her call for five days and did not want to see her until 12 weeks into the pregnancy. It was Mrs. Paxson's first pregnancy and she did not want to wait, so even though her policy does not cover any out-of-network services, she and her husband chose a doctor who doesn't take insurance and paid the entire $13,000 fee themselves.

Once their daughter was born 20 months ago, Mrs. Paxson needed a pediatrician but could not find one who was in her plan, accepting new patients and within walking distance. So she again chose an out-of-network doctor.

"We stayed with her for a year and a half because we loved her," Mrs. Paxson said. At her first scheduled visit after the baby was born, the doctor "talked to me for almost three hours. She knew it was our first baby."

But three months ago, Mrs. Paxson switched to an in-network pediatrician, largely because of the cost of the vaccines. "They didn't cover a dime of it," Mrs. Paxson said of her insurance, adding that she was not complaining. "I made informed decisions."

Though data on private practices is scanty, a new survey of 13,575 doctors from around the country by The Physicians Foundation found that over the next one to three years, more than 50 percent plan to take steps that reduce patient access to their services, and nearly 7 percent plan to switch to cash-only or concierge practices, in which patients pay an annual fee or retainer in addition to other fees.

When doctors stop taking regular insurance or drop a health plan, patients are free to take their business elsewhere. If they have health plans that cover out-of-network expenses, these patients may be reimbursed for fees they pay in cash, but probably not for the entire sum.

The cash-upfront trend raises an uncomfortable question. Can the Affordable Care Act, intended to widen access to health care, succeed by expanding insurance coverage if primary-care doctors are walking away from insurance?

"If all it means is that doctors who serve the wealthy are figuring out ways to avoid the hassles of insurance, I'm not sure it's a public policy problem," said Marsha Gold, a senior fellow at Mathematica Policy Research in Washington and an expert on health care financing. "The real problem comes in if it really restricts the choices people have and makes it worse than it is now. We don't really have the data to know."

The country is already facing a shortage of physicians, according to the Association of American Medical Colleges. By 2025, the nation will have 100,000 fewer doctors than needed, according to the association. With fewer medical students choosing to go into primary care, shortages in this area are expected to become especially acute.

Physicians are increasingly feeling shortchanged by insurance companies, said Dr. Bob Hughes, an otolaryngologist in Saratoga Springs who is president of the Medical Society of the State of New York. "Insurance companies do not negotiate with physicians. It's all take-it-or-leave-it contracts," he said.

A June report by the Medicare Payment Advisory Commission, which advises Congress and focuses primarily on the government plan for seniors, suggests adults ages 50 to 64 are having more trouble getting an appointment with a new physician. Some 30 percent of privately insured individuals who were looking for a new primary care doctor in 2011 reported problems finding one, compared with 26 percent in 2008. (Only 14 percent had a problem finding a specialist in 2011.)

Cash-only practices may exacerbate the access problem. Since her doctor stopped accepting her insurance, Kathryn Vanasek, 43, a mother of two in Manhattan, hasn't been back for a checkup or preventive screenings, relying on a new walk-in clinic for urgent problems like an ear infection.

Her annual physical would cost at least $250 out of pocket, Ms. Vanasek said, but she would not get any money back from her insurer until she met the deductible.

"You are making a decision between preventive medicine and reactive medicine," she said.

If you choose to see a physician who will not accept insurance, experts advise a few precautions:

¶Read the fine print on your health insurance policy. Though many plans provide out-of-network coverage, the reimbursement may cover only a fraction of your costs.

¶Try to estimate your out-of-pocket costs in advance so you can pay the physician with money saved in a flexible spending account, which is sheltered from taxes.

¶Ask yourself whether you really must see a doctor who does not take insurance. Is the care really better? Ask acquaintances outside your regular circle for references. If you are willing to travel, you may find a highly recommended physician who takes your insurance.

¶Keep track of your expenses and receipts, file out-of-network claims promptly and keep copies for yourself. Call your insurer to follow up; it is not unusual for an insurance company to lose paperwork.

¶Watch for expenses that will not be reimbursed. Children's vaccines, for instance, may not be reimbursed even if you have out-of-network coverage. The global fee quoted by an obstetrician for childbirth should encompass all care required unless you have complications, need to see another specialist or require a last-minute Caesarean section.

¶Doctors who don't take insurance are likely to refer to others who don't. Make every effort to ensure that expensive services, such as hospitalizations and surgery, are with network providers and that you have the required approvals from your insurer.

A version of this article appeared in print on 10/02/2012, on page D5 of the NewYork edition with the headline: A Possible Price to Pay if Doctors Spurn Insurance.

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Wednesday, October 3, 2012

Vitamin D does not prevent colds, study says - latimes.com

Vitamin D does not prevent colds or infections, study finds

If you're trying to ward off the sniffles, you can take vitamin D supplements out of your shopping cart: A new study reports that dosing with the vitamin does nothing to prevent colds or other forms of upper respiratory tract infections (URTI).

The effect of vitamin D on the immune system has been debated for a long time. Controlled laboratory research has shown that vitamin D has several beneficial effects on the immune system, and some studies conducted in the past have suggested that people with low levels of the vitamin are at higher risk for URTIs. But the authors of the new study, published Tuesday in the Journal of the American Medical Assn., point out that the previous studies were poorly controlled and results have been mixed, calling into question whether the vitamin does anything at all for URTIs.

To answer the question, the researchers, who are based in New Zealand, conducted a randomized trial nicknamed VIDARIS, for "Vitamin D and Acute Respiratory Infection Study." They gave 161 subjects doses of vitamin D once a month for 18 months, and another group of 161 people a placebo. The doses used were those that appeared to have been the most effective against colds in previous studies.

Over the 18-month period, the vitamin D group reported 593 URTI episodes, while the placebo group reported 611 -- an insignificant difference that is likely due to chance, the authors wrote. There were also no differences between groups in days of work missed, or severity of symptoms. In healthy adults at these recommended doses, Vitamin D appeared to have absolutely no ability to reduce the impact of colds.

In an accompanying editorial, Dr. Jeffrey Linder of Harvard Medical School says the study is well-conducted and its results should be trusted. "The VIDARIS trial, which assessed upper respiratory tract infections as they actually occur in the real world, demonstrated that vitamin D supplementation does not reduce the incidence of respiratory tract infections in adults," he wrote.

That means you can probably stash away your vitamin D pills wherever you put your Airborne.

Return to the Booster Shots blog.

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Do Exercise Programs Help Children Stay Fit? - NYTimes.com

Do Exercise Programs Help Children Stay Fit?

Thor Swift

Getting children to be more physically active seems as if it should be so simple. Just enroll them in classes and programs during school or afterward that are filled with games, sports and other activities.

But an important new review of the outcomes of a wide range of different physical activity interventions for young people finds that the programs almost never increase overall daily physical activity. The youngsters run around during the intervention period, then remain stubbornly sedentary during the rest of the day.

For the review, which was published last week in the British medical journal BMJ, researchers from the Peninsula College of Medicine and Dentistry in England collected data from 30 studies related to exercise interventions in children that had been published worldwide between January 1990 and March 2012.

To be included in the review, the studies had to have involved children younger than 16, lasted for at least four weeks, and reported objectively measured levels of physical fitness, like wearing motion sensors that tracked how much they moved, not just during the exercise classes but throughout the rest of the day. The studies included an American program in which elementary school-age students were led through a 90-minute session of vigorous running and playing after school, three times a week. Another program involved Scottish preschool youngsters and 30 minutes of moderate physical playtime during school hours, three times a week.

In each case, the investigators had expected that the programs would increase the children's overall daily physical activity.

That didn't happen, as the review's authors found when they carefully parsed outcomes. The American students, for instance, increased their overall daily physical activity by about five minutes per day. But only during the first few weeks of the program; by the end, their overall daily physical activity had returned to about where it had been before the program began. The wee Scottish participants actually became less physically active over all on the days when they had the 30-minute play sessions.

The review authors found similar results for the rest of the studies that they perused. In general, well-designed, well-implemented and obviously very well-meaning physical activity interventions, including ones lasting for up to 90 minutes, added at best about four minutes of additional walking or running to most youngsters' overall daily physical activity levels.

The programs "just didn't work," at least in terms of getting young people to move more, said Brad Metcalf, a research fellow and medical statistician at Peninsula College, who led the review.

Why the programs, no matter their length, intensity or content, led to so little additional daily activity is hard to understand, Dr. Metcalf said, although he and his co-authors suspect that many children unconsciously compensate for the energy expended during structured activity sessions by plopping themselves in front of a television or otherwise being extra sedentary afterward. It is also possible, he said, that on a practical level, the new sessions, especially those taking place after school, simply replace time that the youngsters already devoted to running around, so the overall additive benefit of the programs was nil.

But the broader and more pressing question that the new review raises is, as the title of an accompanying editorial asks, "Are interventions to promote physical activity in children a waste of time?"

Thankfully, the editorial's authors answer with an immediate and emphatic "no." If existing exercise programs aren't working, finding new approaches that do work is essential, they say.

They point out that active children are much more likely to be active adults and that physically active children also are far less likely to be overweight. A convincing, if separate body of scientific evidence has shown that the most physically active and fit children are generally the least heavy.

So if structured classes and programs are not getting children to move more, what, if anything, can be done to increase physical activity in the young? "It's a really difficult problem," said Frank Booth, a professor of physiology at the University of Missouri-Columbia, who was not involved with the review.

Determining the most effective placement of classes and programs, so that they don't substitute for time already spent running around and instead augment it, would help, he said.

But a more vital element, he said, "involves mothers and fathers," who can encourage children to leave the couch, subverting their drive to compensate for energy expended earlier by sitting now.

A welcoming setting may also be key, the authors of the accompanying editorial wrote, pointing to a 2011 study of same-sex twins, ages 9 to 11. In that study, the most important determinant of how much the youngsters moved — or didn't — was their local built environment. Children with more opportunities to be outside, in a safe, well-designed space, were more likely to be outside, romping.

But none of these suggestions will be easy to put in place, Dr. Booth said, or inexpensive, and all will require scientific validation. No one expected, after all, that well-designed exercise interventions for children would prove to be so ineffective.

Ultimately, he continued, the best use of resources in this field may be to direct them toward unearthing the roots of childhood inactivity. "Kids naturally love to run around and play," Dr. Booth said. "But they're just not doing it as much now. And we don't know why. So what we really need to understand is, what's happening to our kids that makes them quit wanting to play?"

Phys Ed

Gretchen Reynolds on the science of fitness.

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