Two Rules

There are two rules for success in life

Rule 1: Don't tell people everything you know.



Posted by Scott W. Yates, MD, MBA, MS, FACP

Cholesterol Drugs May Protect Prostate, Sex Potency, Study Says

From Bloomberg News

Cholesterol drugs taken to prevent heart attacks may also lower the risk of prostate cancer and impotence in aging men, researchers said.

Men taking any of several different statin drugs for their cardiovascular health had a threefold lower chance of being diagnosed with prostate cancer compared with those not taking the drugs, according to a 15-year study of men ages 40 to 79 by the Mayo Clinic of Rochester, Minnesota. Those taking any of the medicines, including Merck & Co.’s Zocor and Pfizer Inc.’s Lipitor, also had a lower incidence in later years of erectile dysfunction, benign prostate enlargement and urinary problems.

Prostate cancer is the leading malignancy affecting men and the second deadliest, with 186,320 cases and 28,660 deaths in the U.S. in 2008, said the American Cancer Society. The new research may not reflect a true drop in prostate cancer, the authors said, because statins may merely lower the levels of one indicator, prostate specific antigen, rather than cancer itself.

“If you are taking a statin for a heart condition or to lower cholesterol, these studies suggest that statins could have other benefits,” said study author Jennifer St. Sauver, a Mayo Clinic epidemiologist. “It’s clear we need more information before men are advised to start taking statins for their urological health.”

The findings, being presented at the American Urological Association meeting in Chicago, came from a long-term observational study of 2,447 men in Olmstead County, Minnesota. Beginning in 1990, the study tracked the varied effects of statin use on men’s health as they age, researchers said.

Mixed History

An American Cancer Society official urged caution in interpreting the results, noting that statin cancer studies have a history of mixed results.

“We’ve had studies over the course of several years that suggested statins have a protective or preventive effect with respect to certain cancers. Subsequent studies failed to support that observation,” said J. Leonard Lichtenfeld, deputy chief medical officer of the society in an April 24 telephone interview. “Are there other potential explanations for what you’re seeing? There may be an association but not causation.”

A previous study of 1 million people observed by the American Cancer Society’s CPS-II research found no effect of statins on cancer, he said.

Funding Disclosed

The Mayo Clinic research was funded by the U.S. National Institutes of Health and by the research unit of Merck, St. Sauver said.

One-third of the 2,447 men in the study were taking one of several statins. Of those, 38 men, or 6 percent, were diagnosed with prostate cancer. Men not taking statins were three times more likely to develop prostate cancer, researchers said.

Until now there has been limited evidence to support a theory that statins could protect against development of cancer, researchers said. “Our research provides evidence that statin use is associated with a threefold reduced risk of being diagnosed with prostate cancer,” said study leader Rodney Breau, a Mayo urologic oncology fellow, in a statement.

While previous studies have suggested a link between statins and prostate cancer prevention, St. Sauver said the strength of the association found in the study was a surprise. “It’s very strong. I must say we were pretty excited,” she said in an April 24 telephone interview.

Preliminary

The findings are preliminary, said senior author Jeffrey Karnes, a Mayo Clinic urologist. He added that more medical trials are needed to determine whether statins prevent prostate cancer.

“In the United States, one in six men will develop prostate cancer,” Karnes said in a statement. “Far more will develop heart disease. I tell my patients to take care of their heart -- because what’s good for the heart is also good for the prostate.”

The prostate, a chestnut-shaped gland beneath the bladder that makes semen to transport sperm, is enlarged in one in four men ages 40 to 50 and half of men ages 70 to 80.

Statins are known to lower prostate specific antigen, a protein that is tested in the blood to assess the chance of prostate cancer, St. Sauver said. In this study, statin drugs may have simply lowered PSA so the men were “less likely to go for a biopsy and get a diagnosis of prostate cancer,” rather than actually preventing tumors, she added.

Participants in the study group took an array of different statin drugs, St. Sauver said, with 40 percent being given simvastatin, marketed as Zocor by Whitehouse Station, New Jersey-based Merck, and 35 percent taking atorvastatin, marketed as Lipitor by New York-based Pfizer. Others took products such as lovastatin, sold by Merck as Mevacor, and pravastatin, sold by Bristol-Myers Squibb Co. as Pravachol.

Sexual Impact

Researchers also reported men’s ability to have erections benefited from statin use in those ages 60 or older, and in younger men as well on long-term statin use. Those who took statins for nine years were 64 percent less likely to develop erectile dysfunction than those who didn’t take the drugs, while men who took statins for fewer than three years showed no reduction in risk for that problem.

The study also found benign prostate enlargement was 57 percent less likely and urinary problems 63 percent less likely in men taking statins than in the others, researchers said.

“Statins have been shown to have anti-inflammatory effects, and previous research suggests inflammation may be associated with benign prostate disease,” said St. Sauver.

Limitations of Olmstead County study included the fact that all participants were white, making it hard to extend the findings to other ethnic groups, she said in the interview.

Posted by Scott W. Yates, MD, MBA, MS, FACP

Winning the Football Game

"The best way to beat the Dolphins is to outscore them."

-- John Madden, former NFL coach

Posted by Scott W. Yates, MD, MBA, MS, FACP

20 Minutes

Within 20 minutes after you smoke that last cigarette, your body begins a series of changes that continue for years.

20 Minutes After Quitting
Your heart rate drops.

12 hours After Quitting
Carbon monoxide level in your blood drops to normal.

2 Weeks to 3 Months After Quitting
Your heart attack risk begins to drop.
Your lung function begins to improve.

1 to 9 Months After Quitting
Your coughing and shortness of breath decrease.

1 Year After Quitting
Your added risk of coronary heart disease is half that of a smoker’s.

5 Years After Quitting
Your stroke risk is reduced to that of a nonsmoker’s 5-15 years after quitting.

10 Years After Quitting
Your lung cancer death rate is about half that of a smoker’s.
Your risk of cancers of the mouth, throat, esophagus, bladder, kidney, and pancreas decreases.

15 Years After Quitting
Your risk of coronary heart disease is back to that of a nonsmoker’s.

From the 2004 Surgeon General’s Report - The Health Consequences of Smoking (available at http://www.cdc.gov/)

Smoking cessation resources also available at: http://www.cancer.gov/cancertopics/tobacco/quittingtips

Posted by Scott W. Yates, MD, MBA, MS, FACP

Committees

"Twelve experts gathered in one room equals one big idiot."

-- Carl Jung



"A committee is an animal with four back legs."

-- John Le Carre



"A committee is a cul-de-sac down which ideas are lured and then quietly strangled."

-- Sir Barnet Cocks



"Committee - a group of the unfit, appointed by the unwilling, to do the unnecessary."

-- Stewart Harrol

Posted by Scott W. Yates, MD, MBA, MS, FACP

10 Symptoms of Adult ADHD

10 Symptoms of Adult ADHD

Many people think of rowdy kids who can’t sit still when they think of attention deficit hyperactivity disorder, or ADHD. But the fact is, symptoms of ADHD can linger into adulthood. In fact, many adults with ADHD aren’t aware they have it and don’t realize that many of the problems they face, including staying organized or being on time, are symptoms of adult ADHD.

What Causes Adult ADHD?

While experts don’t know for sure what causes ADHD, they believe genes may play an important part in who develops attention deficit hyperactivity disorder. Environmental issues, such as exposure to cigarettes or alcohol while in the womb, may also play a role.

Unlike other psychiatric disorders, including anxiety and depression, ADHD can’t develop in the adult years. So symptoms must have been present since childhood for a diagnosis of adult ADHD to be made.

10 Adult ADHD Symptoms

The conventionally used diagnostic criteria for ADHD, including the most common symptoms, were developed based on how the condition shows itself in children.

These symptoms include forgetfulness and excessive daydreaming, as well as an inability to sit still, or constant fidgeting with objects.

Yet many experts think adult attention deficit hyperactivity disorder symptoms manifest themselves differently and more subtly. This can make it difficult to recognize and diagnose adult ADHD.

Adult ADHD Symptom No. 1: Problems Getting Organized

For people with ADHD, the increased responsibilities of adulthood -- bills, jobs, and children, to name a few -- can make problems with organization more obvious and more harmful than in childhood. While some ADHD symptoms are more annoying to other people than to the person with the condition, disorganization is often identified by adults struggling with ADHD as a major detractor from quality of life.

Adult ADHD Symptom No. 2: Reckless Driving and Traffic Accidents

Attention deficit hyperactivity disorder makes it hard to keep your attention on a task, so spending time behind the wheel of a car can be difficult. Because of this, ADHD can make some people more likely to speed, have traffic accidents, and lose their driver’s licenses.

Adult ADHD Symptom No. 3: Marital Problems

Many people without ADHD have marital problems, of course, so a troubled marriage shouldn’t be seen as a red flag for adult ADHD. But there are some marriage problems that are particularly likely to affect the relationships of those with ADHD. Often, the partners of people with undiagnosed ADHD take poor listening skills and an inability to honor commitments as a sign that their partner doesn’t care. If you’re the person suffering from ADHD, you may not understand why you’re partner is upset, and you may feel you’re being nagged or blamed for something that’s not your fault.

Adult ADHD Symptom No. 4: Extreme Distractibility

Attention deficit hyperactivity disorder is a problem with attention regulation, so adult ADHD can make it difficult to succeed in today’s fast-paced, hustle-bustle world. Many people find that distractibility can lead to a history of career underperformance, especially in noisy or busy offices. If you have adult ADHD, you might find that phone calls or email derail your attention, making it hard for you to finish tasks.

Adult ADHD Symptom No. 5: Poor Listening Skills

Do you zone out during long business meetings? Did your husband forget to pick up little Jimmy at baseball practice, even though you called to remind him on his way home? Problems with attention result in poor listening skills in many adults with ADHD, leading to a lot of missed appointments and misunderstandings.

Adult ADHD Symptom No. 6: Restlessness, Problems Relaxing

While many children with ADHD are “hyperactive,” this ADHD symptom often appears differently in adults. Rather than bouncing off the walls, adults with ADHD are more likely to exhibit restlessness or find they can’t relax. If you have adult ADHD, others might describe you as edgy or tense.

Adult ADHD Symptom No. 7: Problems Starting a Task

Just as children with ADHD often put off doing homework, people with adult ADHD often drag their feet when starting tasks that require a lot of attention. This procrastination often adds to existing problems, including marital disagreements, workplace issues, and problems with friends.

Adult ADHD Symptom No. 8: Chronic Lateness

There are many reasons adults with attention deficit hyperactivity disorder are usually late. First, they’re often distracted on the way to an event, maybe realizing the car needs to be washed, and then noticing they’re low on gas, and before they know it an hour has gone by. People with adult ADHD also tend to underestimate how much time it takes to finish a task, whether it’s a major assignment at work or a simple home repair.

Adult ADHD Symptom No. 9: Angry Outbursts

Attention deficit hyperactivity disorder often leads to problems controlling emotions. Many people with adult ADHD are quick to explode over minor issues. Often, the person with ADHD feels as if they have absolutely no control over their emotions. Many times, their anger fades as quickly as it flared, long before the people who dealt with the outburst have gotten over the incident.

Adult ADHD Symptom No. 10: Prioritizing Issues

Attention deficit hyperactivity disorder can wreak havoc on planning, too. Often, people with adult ADHD mis-prioritize, failing to meet big obligations, like a deadline at work, while spending countless hours on something insignificant, such as getting a higher score on a video game.

From WebMD

Posted by Scott W. Yates, MD, MBA, MS, FACP

The Art of Medicine

"The art of medicine consists in amusing the patient while nature cures the disease."

-- Voltaire (1694 - 1778)

Posted by Scott W. Yates, MD, MBA, MS, FACP

More Bad News For Antioxidant Vitamins

Taking antioxidant vitamins (such as vitamin C and vitamin E) has been promoted as beneficial in prevention of colds, heart attack, stroke and cancer. Unfortunately, it appears that none of these illnesses are prevented by taking vitamins. And worse yet, evidence has accumulated that antioxidant vitamins can be harmful.

The most recent study, published in the Proceedings of the National Academy of Sciences demonstrated that taking supplemental vitamin C and vitamin E eliminated one of the major benefits of exercise in healthy men. The study included 40 healthy German men, half were previously sedentary and half not. In each of these two groups, half were given vitamin C and E supplements and half placebo. All underwent measurement of insulin sensitivity (the body’s ability to respond to insulin and control blood sugar – known to predict development of diabetes) before and after exercise training.

Insulin sensitivity improved in the men who were given placebo tablets but did not in those given vitamin supplements. The authors conclude (and we agree) that taking vitamin C and vitamin E prevent this beneficial impact of exercise.

A recent review of 67 studies (involving over 230,000 participants) concluded that vitamin C (alone or in combination with other vitamins) did not lower mortality. The same review concluded that vitamin E supplementation (as well as supplementation with vitamin A and beta-carotene) may to increase mortality significantly.

The recent German study describing the negative impact of vitamins C and E on the benefit of exercise joins a list of prior trials suggesting that in some patients these vitamins can increase risk of stroke and heart attack.

We do not recommend routine supplementation with vitamins A, C, E or beta-carotene.

Comments / Posted by Scott W. Yates, MD, MBA, MS, FACP

Flu Pandemic Update 05/15/09

Daniel Jernigan, MD, PhD (deputy director of the Centers for Disease Control) said during a news conference today that more than 100,000 Americans probably have the flu – and at least 50,000 are H1N1 swine flu. While only about 7,500 cases have been confirmed worldwide (4,750 in the U.S.), the vast majority of those who are ill are not tested.

At a time when flu season should be ending or over, the CDC's flu season indicators are going up instead of down. As of May 9, 22 states had widespread or regional flu. The CDC's most recent data, for the week ending May 9, shows that about half of Americans with confirmed flu had the H1N1 swine flu.

One of the most alarming signs of a flu pandemic is a lot of severe illness in people who don't usually suffer severe flu cases -- older children and young adults. Most of the 173 people hospitalized in the U.S. with H1N1 swine flu have been between 5-24 years old.

H1N1 swine flu has killed 1/114 patients with confirmed infection worldwide (and 1/1,200 in the U.S.). This is a much higher mortality rate than seasonal influenza. If Dr. Jernigan’s estimate is correct and there have been 4 deaths among 50,000 infections, the mortality rate of 1/12,500 is more similar to seasonal influenza. However, this assumes that all deaths due to H1N1 have been reported – also unlikely, so the mortality rate may be higher or lower.

Seasonal influenza kills between 1/1,000 (in age > 65) and 1/200,000 (age < 50). About 90% of deaths due to seasonal influenza occur in individuals age 65 or older. This does not appear to be the case for H1N1 swine flu.
We continue to recommend isolation and influenza testing for anyone who develops a febrile illness; prompt treatment with Tamiflu for those who test positive is appropriate. We do not recommend limiting Tamiflu treatment of flu-test positive patients to only those with other illnesses given the severity of illness seen with H1N1 in young, otherwise healthy individuals.

Standard precautions (hand washing, etc.) should also be continued.

Comments / Posted by Scott W. Yates, MD, MBA, MS, FACP

Time to Act

"The best time to plant a tree... was twenty years ago. The second best time...is today."

-- Chinese saying

Posted by Scott W. Yates, MD, MBA, MS, FACP

Signing On to an Obama 'Dream'

Editorial Opinion - The Wall Street Journal

Health providers agree to Obama health plan's notion of cost savings

At a news conference yesterday, President Obama said, "I will not rest until the dream of health-care reform is achieved in the United States of America." Normally dreams cost you nothing, but Mr. Obama's determination not to rest until his becomes reality is likely to cost plenty. Yesterday a coalition of private health-system providers, seeing no exit from the administration's reform plans, signed on to the dream.

They agreed in principle to try to shave 1.5 percentage points off the growth rate of U.S. health-care costs over the next decade, about $2 trillion. This vague, probably illusory promise isn't much as a matter of policy, but it is a major political development in what is the Obama Presidency's No. 1 priority.

The private groups are calculating that they can better influence this year's bill if they're "partners" instead of villains. They've no doubt seen what happened to Wall Street and Chrysler bondholders. All the same, they must surely know they have made a Faustian bargain that in time will result in price controls and restrictions on care.

The Obama Administration, by contrast, is convinced that it is smart enough to engineer more efficient medical practices out of D.C. The dominant White House voice on health policy is Peter Orszag, the budget chief. He cites research out of Dartmouth that shows health-care spending varies wildly between regions, often with little or no correlation to health outcomes.

Mr. Orszag champions "comparative effectiveness research" -- studying the patterns of clinical practice to determine which drugs and treatments work best. The Administration thinks it can use such analysis to weed out wasteful or unnecessary care by paying more "if the treatment has been shown to be effective and a little less if not," as Mr. Orszag recently told the New Yorker.

The irony is that the history of post-1965 U.S. health care policy is littered with similar government attempts to control health spending, not least comparative effectiveness. The "managed care" movement of the 1990s grew directly out of the peer-review panels created by Congress in 1972 to monitor the quality and appropriateness of care for Medicare and Medicaid patients.

Under managed care, doctors and hospitals had to undergo prior "utilization review" by HMOs to reduce unnecessary hospitalizations, surgeries, tests, prescriptions and so on. This cost-effectiveness gatekeeping disciplined health spending. What happened next to this version of the dream is known to all.

Administrative hassles led to a consumer backlash, with patients feeling they were getting inferior care in return for insurer profits. The political class eventually forced the HMOs to dilute or end most of their cost-control strategies.

Democrats have now acknowledged that the managed care dream will work only if government is the one doing the managing. That is, we can only control costs with a new government entitlement. More is less.

But you can only allocate a scarce resource in two ways: market prices or brute force. In health care the brute force will come as price controls and waiting lines for rationed services. The implicit assumption in the providers' deal announced yesterday seems to be that the private companies will do the price controlling so the government won't have to do it for them. But when the savings prove illusory, as in the past, the feds will step in and order them to do so. To win a false reprieve for themselves and give cost cover to the politicians, these private CEOs are offering to make themselves even more unpopular with patients. By that point, most patients will have no choice but to assent, since most of them will be in one government program or another.

Lest anyone remains in doubt about the ultimate goal here, Ralph Neas of the leftist National Coalition on Health Care got out a quick statement throwing ice water on the industry's concession. With perfect clarity Mr. Neas said: "Voluntary efforts -- without legislated requirements and enforcement -- have not worked well in the past."

The only benefit here is that it is now possible to see where this issue is headed: A new legislated entitlement for the middle class will ensure that the next great health-care argument to engulf the political system is going to be over how and when to ration care.

Printed in The Wall Street Journal, page A16

Posted by Scott W. Yates, MD, MBA, MS, FACP

How ObamaCare Will Affect Your Doctor

From The Wall Street Journal
By Scott Gottlieb, MD

Expect longer waits for appointments as physicians get pinched on reimbursements.

At the heart of President Barack Obama's health-care plan is an insurance program funded by taxpayers, administered by Washington, and open to everyone. Modeled on Medicare, this "public option" will soon become the single dominant health plan, which is its political purpose. It will restructure the practice of medicine in the process.

Republicans and Democrats agree that the government's Medicare scheme for compensating doctors is deeply flawed. Yet Mr. Obama's plan for a centrally managed government insurance program exacerbates Medicare's problems by redistributing even more income away from lower-paid primary care providers and misaligning doctors' financial incentives.

Like Medicare, the "public option" will control spending by using its purchasing clout and political leverage to dictate low prices to doctors. (Medicare pays doctors 20% to 30% less than private plans, on average.) While the public option is meant for the uninsured, employers will realize it's easier -- and cheaper -- to move employees into the government plan than continue workplace coverage.

The Lewin Group, a health-care policy research and consulting firm, estimates that enrollment in the public option will reach 131 million people if it's open to everyone and pays Medicare rates, as many expect. Fully two-thirds of the privately insured will move out of or lose coverage. As patients shift to a lower-paying government plan, doctors' incomes will decline by as much as 15% to 20% depending on their specialty.

Physician income declines will be accompanied by regulations that will make practicing medicine more costly, creating a double whammy of lower revenue and higher practice costs, especially for primary-care doctors who generally operate busy practices and work on thinner margins. For example, doctors will face expenses to deploy pricey electronic prescribing tools and computerized health records that are mandated under the Obama plan. For most doctors these capital costs won't be fully covered by the subsidies provided by the plan.

Government insurance programs also shift compliance costs directly onto doctors by encumbering them with rules requiring expensive staffing and documentation. It's a way for government health programs like Medicare to control charges. The rules are backed up with threats of arbitrary probes targeting documentation infractions. There will also be disproportionate fines, giving doctors and hospitals reason to overspend on their back offices to avoid reprisals.

The 60% of doctors who are self-employed will be hardest hit. That includes specialists, such as dermatologists and surgeons, who see a lot of private patients. But it also includes tens of thousands of primary-care doctors, the very physicians the Obama administration says need the most help.

Doctors will consolidate into larger practices to spread overhead costs, and they'll cram more patients into tight schedules to make up in volume what's lost in margin. Visits will be shortened and new appointments harder to secure. It already takes on average 18 days to get an initial appointment with an internist, according to the American Medical Association, and as many as 30 days for specialists like obstetricians and neurologists.

Right or wrong, more doctors will close their practices to new patients, especially patients carrying lower paying insurance such as Medicaid. Some doctors will opt out of the system entirely, going "cash only." If too many doctors take this route the government could step in -- as in Canada, for example -- to effectively outlaw private-only medical practice.

These changes are superimposed on a payment system where compensation often bears no connection to clinical outcomes. Medicare provides all the wrong incentives. Its charge-based system pays doctors more for delivering more care, meaning incomes rise as medical problems persist and decline when illness resolves.

So how should we reform our broken health-care system? Rather than redistribute physician income as a way to subsidize an expansion of government control, Mr. Obama should fix the payment system to align incentives with improved care. After years of working on this problem, Medicare has only a few token demonstration programs to show for its efforts. Medicare's failure underscores why an inherently local undertaking like a medical practice is badly managed by a remote and political bureaucracy.

But while Medicare has stumbled with these efforts, private health plans have made notable progress on similar payment reforms. Private plans are more likely to lead payment reform efforts because they have more motivation than Medicare to use pay as a way to achieve better outcomes.

Private plans already pay doctors more than Medicare because they compete to attract higher quality providers into their networks. This gives them every incentive, as well as added leverage, to reward good clinicians while penalizing or excluding bad ones. A recent report by PriceWaterhouse Coopers that examined 10 of the nation's largest commercial health plans found that eight had implemented performance-based pay measures for doctors. All 10 plans are expanding efforts to monitor quality improvement at the provider level.

Among the promising examples of private innovation in health-care delivery: In Pennsylvania, the Geisinger Clinic's "warranty" program, where providers take financial responsibility for the entire episode of care; or the experience of the Blue Cross Blue Shield plans in Pennsylvania, Michigan and Virginia, where doctors are paid more for delivering better outcomes.

There are plenty of alternatives to Mr. Obama's plan that expand coverage to the uninsured, give them the chance to buy private coverage like Congress enjoys, and limit government management over what are inherently personal transactions between doctors and patients.

Rep. Nydia Velazquez (D., N.Y.) has introduced a bipartisan measure, the Small Business Cooperative for Healthcare Options to Improve Coverage for Employees (Choice) Act of 2009, that would make it cheaper and easier for small employers to offer health insurance. Mr. Obama would also get bipartisan compromise on premium support for people priced out of insurance to give them a wider range of choices. This could be modeled after the Medicare drug benefit, which relies on competition between private plans to increase choices and hold down costs. It could be funded, in part, through tax credits targeted to lower-income Americans.

There are also measures available that could fix structural flaws in our delivery system and make coverage more affordable without top-down controls set in Washington. The surest way to intensify flaws in the delivery of health care is to extend a Medicare-like "public option" into more corners of the private market. More government control of doctors and their reimbursement schemes will only create more problems.

Dr. Gottlieb, a former official at the Centers for Medicare and Medicaid Services, is a fellow at the American Enterprise Institute and a practicing internist.

Printed in The Wall Street Journal, page A17

Posted by Scott W. Yates, MD, MBA, MS, FACP

Flu Pandemic Update 05/12/09

Swine Flu Is as Severe as Pandemic Virus in 1957, Study Shows

May 12 (Bloomberg News) -- The swine flu strain that has sickened people in 30 countries rivals the severity of the 1957 "Asian flu" pandemic that killed 2 million people, scientists said.

About four of 1,000 people infected with the new H1N1 strain in Mexico by late April died, according to a study published yesterday in the journal Science that was led by Neil Ferguson of the Imperial College London. Seasonal flu epidemics cause 250,000 to 500,000 deaths each year, the World Health Organization has said.

Scientists are trying to determine whether swine flu will mutate and become more deadly as it spreads to the Southern Hemisphere and back. The virus is more contagious than seasonal flu, the Geneva-based WHO said yesterday. A "moderate" pandemic like the 1957 Asian flu could kill 14.2 million people and shave 2 percent from the global economy in the first year, the World Bank said in October.

"While substantial uncertainty remains, clinical severity appears less than that seen in 1918 but comparable with that seen in 1957," the Science study authors wrote.

Flu pandemics occur when a strain of the disease to which few people have immunity evolves and begins spreading. Pandemics usually occur two to three times a century, scientists have said. A worldwide outbreak as severe as the 1918 Spanish flu might cause 180 million to 260 million deaths, the World Bank said, citing a 2005 study in the New England Journal of Medicine.

The last pandemic hit in 1968, and health officials have been anticipating another since the H5N1 strain began spreading widely in birds in 2003.

World Spread

Swine flu has been confirmed in 4,694 people, according to the WHO, the health agency of the United Nations. Sixty-one people have died, including 56 in Mexico, three in the U.S., and one each in Canada and Costa Rica, health officials said. The U.S. confirmed 2,618 cases in 44 states, according to the Centers for Disease Control and Prevention.

Each person infected with swine flu in Mexico in April gave it to 1.4 more people on average, the study said. While that's in the lower range of transmission speed for a pandemic virus, it's quicker than most seasonal flus, the authors said.

An estimated 23,000 people in Mexico were infected by late April, the researchers said. That number was based on case reports and assumptions about the speed of spread, and may have been as high as 32,000 and as low as 6,000, according to the study.

More Contagious

In seasonal flu, each person who comes in contact with someone who's sick has a 5 percent to 15 percent probability of illness, according to a statement on the WHO's Web site. In swine flu, the probability increases to 22 percent to 33 percent, WHO said.

Swine flu has been "overwhelmingly mild outside Mexico," the WHO statement said. The reason for that variation "is still not fully understood," it said.

Swine flu is making more young people seriously ill, compared with seasonal flu, and "is of particular concern" because it's causing more significant medical effects in people with other health conditions, the WHO said.

Posted by Scott W. Yates, MD, MBA, MS, FACP

Happy Mother's Day

Can people predict the future with cards?
My mother can.
Really?
Yes, she takes one look at my report card and tells me what will happen when my father gets back home.



"It takes a woman twenty years to make a man of her son, and another woman twenty minutes to make a fool of him."

-- Helen Rowland



"My mother had a great deal of trouble with me, but I think she enjoyed it."

-- Mark Twain



"My mother's menu consisted of two choices: Take it or leave it."

-- Buddy Hackett



"A mother is not a person to lean on, but a person to make leaning unnecessary."

-- Dorothy Canfield Fisher



"A man loves his sweetheart the most, his wife the best, but his mother the longest."

-- Irish Proverb



"All women become like their mothers. That is their tragedy.

No man does. That's his."

--Oscar Wilde, The Importance of Being Earnest, 1895



"The most important thing that a father can do for his children is to love their mother."

-- Theodore M. Hesburgh


Posted by Scott W. Yates, MD, MBA, MS, FACP

The Fine Print: What's Really in a Lot of 'Healthy' Foods

From The Wall Street Journal

A lot of Americans think they're eating a healthy diet these days. But it's easy to be fooled by our assumptions and the ways that food manufacturers play on them.

Take chicken. The average American eats about 90 pounds of it a year, more than twice as much as in the 1970s, part of the switch to lower-fat, lower-cholesterol meat proteins. But roughly one-third of the fresh chicken sold in the U.S. is "plumped" with water, salt and sometimes a seaweed extract called carrageenan that helps it retain the added water. The U.S. Department of Agriculture says chicken processed this way can still be labeled "all natural" or "100% natural" because those are all natural ingredients, even though they aren't naturally found in chicken.

Producers must mention the added ingredients on the package -- but the lettering can be small: just one-third the size of the largest letter in the product's name. If you're trying to watch your sodium to cut your risk of high blood pressure, heart attack and stroke, it pays to check the Nutrition Facts label. Untreated chicken has about 45 to 60 mgs of sodium per four-ounce serving. So-called enhanced or "plumped" chicken has between 200 and 400 mgs of sodium per serving, almost as much as a serving of fast-food french fries.

Adding salt water became widespread when big discount stores began selling groceries and wanted to sell chicken at uniform weights and prices. Plumping packaged chicken helps even out the weight. But that means consumers are paying for added salt water at chicken prices -- an estimated $2 billion worth every year, according to the Truthful Labeling Coalition, a group of chicken producers that don't enhance their products.

Makers of enhanced chicken, including some of the biggest U.S. producers, say many consumers prefer it in blind taste tests and that it stays moister. Ray Atkinson, a spokesman for Pilgrim's Pride, says the company sells both enhanced and unenhanced chicken because consumers ask for it. He also notes that even at 330 mg of sodium, the enhanced chicken qualifies for the American Heart Association's mark of approval.

A survey released this week from Foster Farms, a member of the Truthful Labeling Coalition, found that 63% of consumers are unaware of the practice, and 82% believe that salt-water-injected chicken shouldn't carry the all-natural label. The telephone survey polled 1,000 consumers on the West Coast.

Here are some other foods that may not be as healthy as they appear.

Salt substitutes. If you're trying to cut down on salt, check with your doctor before you start using a salt substitute. Most contain potassium chloride, which can exacerbate kidney problems and interact badly with some heart and liver medications.

Artificial Sweeteners. Sugar-free gum, mint and candy have fewer calories and are better for your teeth. But they frequently contain sorbitol, a plant extract that isn't completely absorbed by the body and works as a natural laxative. Consuming a single pack of gum or mints can cause bloating, flatulence, stomach pains and diarrhea in people who are sensitive to it. Some diabetics find that such sugar alcohols, which are sweet but have few calories, can raise their blood sugar. Others include maltitol and xylitol.

Trans fat. There's been a remarkable reduction in these artery-cloggers in processed foods recently. But manufacturers are allowed to round down: Products labeled zero grams of trans fat can have up to 0.49 gram of fat per serving. You could still be consuming significant amounts of trans fat, "especially when the serving size is unrealistic," says Bonnie Taub-Dix, a nutritionist and spokeswoman for the American Dietetic Association, a nonprofit professional organization. If the ingredients include partially hydrogenated oil, hydrogenated oil or shortening, a product isn't completely trans-fat free. And it may have considerable saturated fat as well.

The same rounding principle applies to zero calories, fat and carbohydrates. Walden Farms, which advertises a line of dips, spreads and dressings as "Fat Free, Sugar Free and Calorie Free," says its products do have trace calories and up to 0.49 gram of fat and carbohydrates per serving.

"Wheat bread." This is a meaningless term, since almost all bread is made with wheat. Some manufacturers add to the illusion by using a brown wrapper or darkening bread with brown sugar or molasses. The more healthful stuff is whole wheat, which includes the outer bran and the wheat germ inside, good sources of nutrients and fiber. Check the ingredients. If the first one listed is "enriched wheat flour," you aren't getting much whole grain.

A few bread makers are still displaying the USDA's old Food Pyramid on their packages -- the one that recommended six to 11 servings of bread or pasta a day. That's been replaced by a more individualized pyramid that recommends only six carbohydrate servings, three of which should be whole grains.

Fiber. Companies are adding fiber to all kinds of products -- including yogurt, ice cream and beverages. In many cases, the added fiber comes from purified powders, not the kind of fiber found in whole grains, beans, vegetables and fruits. The latter have been shown to lower cholesterol, reduce the risk of diabetes and heart disease and may cut the risk of colon cancer. But there isn't much evidence that "isolated" fibers like inulin, maltodextrin, oat fiber and polydextrose have the same effect, according to the Center for Science in the Public Interest, a nonprofit consumer-advocacy group. The Nutrition Facts label doesn't differentiate between the kind of fiber counted, so check the ingredients.

"The added fiber is probably better than nothing, but it's not as good as fiber from natural sources like fruits, vegetables and whole grains," says CSPI Executive Director Michael Jacobson.

Yogurt. The yogurt aisle is dizzy these days with products that promise to reduce your cholesterol, control your blood pressure, protect your digestive health or boost your immune system. In many cases, it's a single ingredient that provides the benefit, and you can find much more of it in other sources. For example, Promise activ SuperShots say they "Help Control Blood Pressure" thanks to 350 mgs of potassium. There's much more potassium in a banana, a cup of spinach or a baked potato. DanActive probiotic dairy drink's immunity-boosting claims stem from its L. casei Immunitas active culture. There's lots of research interest in such probiotics, but for now, the marketing is ahead of the science. The friendly bacteria in DanActive has mainly been shown to fight diarrhea in people taking antibiotics.

Super water. The Center for Science in the Public Interest sued Coca-Cola Co. earlier this year over claims on its VitaminWater beverages. The center argued that the drinks -- with names like "defense," "rescue," "energy" and "endurance" -- are mainly sugar water with 125 calories per bottle. Coke called the lawsuit "frivolous" and said its VitaminWater brands are properly labeled. "Consumers today are savvy, they are educated and they are looking for more from their beverages than simply hydration," said Coke spokesman Scott Williamson.

Government surveys show that most Americans aren't deficient in many of the vitamins supplied in these drinks. If you consume more than you need, the excess gets excreted.

Omega 3. Many foods are adding these essential fatty acids, said to cut the risk of heart disease, cancer and arthritis and help promote brain health. But you can get a lot more from natural foods. You'd need to drink 45 eight-ounce glasses of milk that is fortified with 32 mgs of omega 3 to get as much of these fatty acids as you get in a three-ounce serving of salmon.

Will any of the products mentioned here hurt you? No, but they may not help you as much as manufacturers would like you to think. "Try to buy foods as close to their natural state as possible," says Ms. Taub-Dix.

Printed in The Wall Street Journal, page D1

Posted by Scott W. Yates, MD, MBA, MS, FACP

Flu Pandemic Update 05/06/09

Another US Death But Probably Waning Risk Overall
From The Wall Street Journal

A woman living near the Mexican border in south Texas became the second person in the U.S. to die of a new strain of flu, as the virus causing it continued to spread around the globe.

U.S. health officials have warned that the number of deaths is likely to grow as the new H1N1 virus spreads across the country, even though they now believe the new flu isn't as severe as they initially feared.

The woman, who was a U.S. citizen in her early 30s, had "chronic underlying health conditions," according to Texas authorities. She had been hospitalized for about three weeks, after falling ill around April 14. None of her immediate family is ill, they said. They declined to elaborate further.

Texas has been hit hard by the H1N1 virus. The state has had 61 confirmed cases overall, including the only two fatalities in the U.S. Last month, a Mexican toddler who had crossed into Texas with his family to visit relatives succumbed to H1N1 in a Houston hospital. He, too, was described by state officials as being weakened by unrelated health conditions.

The virus continued to spread Tuesday, with 1,490 laboratory-confirmed cases in 23 countries, according to the World Health Organization. Mexico had 822 confirmed cases and 29 deaths. U.S. cases rose to 403, with 700 more probable cases, according to the Centers for Disease Control and Prevention, which also said 62% of the confirmed cases are under age 18. While most cases are mild, 35 people were hospitalized and some have been sick enough to need ventilators to breathe.

The U.S. Navy, meanwhile, said it canceled the deployment of a ship and ordered its entire crew to be treated with antiviral drugs after a crew member's illness was confirmed as swine flu, according to the Associated Press.

Navy spokesman Lt. Sean Robertson said there are also about 50 suspected cases of the virus from crew members on board the USS Dubuque, which is based in San Diego, the AP reported. The ship was scheduled to leave June 1 on a humanitarian mission to the South Pacific.

The Wall Street Journal, page A3
By BETSY MCKAY and STEPHANIE SIMON

U.S. May Add Shots for Swine Flu to Fall Regimen
From the Washington Post

The Obama administration is considering an unprecedented fall
vaccination campaign that could entail giving Americans three flu shots
-- one to combat annual seasonal influenza and two targeted at the new
swine flu virus spreading across the globe.

If enacted, the multibillion-dollar effort would represent the first
time that top federal health officials have asked Americans to get more
than one flu vaccine in a year, raising serious challenges concerning
production, distribution and the ability to track potentially severe
side effects.

Another option, said Dale Morse, chairman of the advisory committee on
immunization practices at the Centers for Disease Control and
Prevention, is adding to the seasonal flu shot an ingredient targeted at
the new virus.

Experts in and out of the administration are evaluating a raft of
complicated issues, including who ought to receive an inoculation
against the swine flu and whether private vaccine makers can
simultaneously manufacture the standard 180 million doses as well as up
to 600 million rounds of a new vaccine.

"We are moving forward with making a vaccine," said Robin Robinson, a
director with the Department of Health and Human Services who oversees
pandemic response programs. Robinson said that although a formal
decision about the swine flu vaccine has not been made, if the
government goes ahead, it would probably produce two doses for all
Americans. If the threat diminishes, he said, health officials could
decide to produce doses for only a portion of the population.

Vaccine and pandemic experts are working with the administration to
determine how to produce, test, track and educate the public about two
different influenza vaccines in the same flu season.

"They have never tried this before, and there is going to be a great
deal of confusion," said William Schaffner, chairman of the Department
of Preventive Medicine at Vanderbilt University School of Medicine.

Memories of the nation's earlier experience with a swine flu vaccine
present another challenge. In 1976, hundreds of Americans developed
neurological disorders after they were vaccinated for a swine flu
strain. The public was asked to receive one of two vaccines developed to
combat the strain.

Health officials have asked manufacturers to ramp up production of the
seasonal vaccine scheduled for rollout this fall to make way for the
possible mass production of a swine flu vaccine.

A decision on whether to produce such a vaccine will have to be made
soon, because it typically takes five months to produce a new vaccine
and authorities would want it available for the next flu season.

Some medical experts said rolling out two vaccines would present
additional challenges in terms of testing and tracking adverse
reactions. Health officials and manufacturers will need to know what the
negative reactions might be for each vaccine on its own and in
combination with the other. Initial tests would be done on animals, and
then clinical trials would be conducted with people to determine side
effects before either vaccine is rolled out.

Harvey Fineberg, president of the Institute of Medicine, part of the
National Academy of Sciences, said officials will have to weigh the
risks of the time spent on testing.

"All this takes time, money and organization," said Fineberg, who led an
investigation into the government's handling of the 1976 swine flu
vaccinations.

The greater challenge will be tracking any adverse reactions as millions
of Americans get multiple vaccinations in a matter of months this fall
and winter.

"There will be adverse effects to any vaccine. That's just science,"
said Michael Hattwick, who ran the CDC's vaccine-tracking system during
the last swine flu scare.

Hattwick said a "real-time" tracking system would need to be established
to provide constant updates to the CDC about adverse reactions. That
information, he said, should include lot numbers for the vaccines so
health officials can trace each side effect to the manufacturer and the
date of production. Routine flu vaccinations are not traced with such
precision because reporting is voluntary and often delayed, Hattwick
said.

Anthony S. Fauci, director of the National Institute of Allergy and
Infectious Diseases, said he does not expect additional adverse
reactions with two vaccinations. The traditional flu vaccine is designed
to attack the three flu strains health officials believe to be the
greatest threats in a regular season, he said.

"In a regular seasonal flu, you get three vaccines. Adding an additional
one should not present a problem," Fauci said.

A record-keeping system would also need to be devised to track which
doses patients have received, health experts said.

Without such a system, patients could lose track of which of the three
shots they have received or could fail to get the second swine flu
inoculation at the proper time.

"We will have to keep them straight and separate," Vanderbilt's
Schaffner said. "This will be an enormous challenge, and we haven't
figured out how to do it yet. That's one of the things we are trying to
sort out."

By Kimberly Kindy and Ceci Connolly
Washington Post Staff Writers
Wednesday, May 6, 2009

Posted by Scott W. Yates, MD, MBA, MS, FACP

Flu Pandemic Update 05/05/09

Public health officials sound more optimistic in recent press briefings and while the number of reported cases continues to rise, the swine H1N1 spread appears to be slowing.

Over 300,000 children are unable to attend school due to infection - related school closings and the CDC is re-evaluating the duration of school closure that may be necessary to prevent further spread. The CDC may scale back its current recommendation to close for up to 14 days any schools attended by, or in areas near, a child who tests positive for the new H1N1 virus as growing evidence suggests most cases of the disease are relatively mild. Updated guidance is expected later this week.

At this point, we no longer believe it necessary for healthy individuals to avoid crowds and commercial air travel, but routine precautions (hand washing, etc.) should be continued. Non-essential travel to Mexico should be delayed if possible.

Anyone who develops a febrile illness should remain isolated until testing for influenza can be performed.

Bottom Line: The situation appears to be improving overall - but don't give up your handwashing habit yet!

Comments / Posted by Scott W. Yates, MD, MBA, MS, FACP

Flu Pandemic Update 05/04/09

Some schools in Dallas, Plano and Frisco (and the entire Lewisville and Fort Worth school districts) have been closed. Parents with children home from (closed) schools may have difficulty with childcare arrangements since many must work. This may prove to be one of the most problematic issues (and valuable lessons) from this scare.

The Big Question: How Dangerous Is It?

As the total number of worldwide cases approaches 1,000 it seems at first glance that the H1N1 influenza virus may prove more lethal than seasonal influenza. To date, of the 985 confirmed cases, there have been 26 deaths (so a mortality rate of about 1/40 infections). Seasonal influenza kills between 1/1,000 (in age > 65) and 1/200,000 (age < 50). The difficulty with comparing these mortality rates is that there are likely a large number of H1N1 infections that have not been diagnosed (some estimate that about 1% have been). That would make the mortality rate about 1/4,000.

About 90% of deaths due to seasonal influenza occur in individuals age 65 or older. We don’t yet know whether this is true for H1N1.

The reason for the aggressive response to this virus is that there is still much we do not know. And, other animal influenza viruses have been much more dangerous. For example, the H5N1 avian influenza: First identified in Italy in 1878, highly pathogenic avian influenza is characterized by sudden onset of severe disease, rapid contagion, and a mortality rate that can approach 100% within 48 hours. The virus not only affects the respiratory tract but also invades multiple organs and tissues. The resulting massive internal haemorrhaging has earned it the lay name of “chicken Ebola”.

Flu Pandemic Update 05/01/09

It's mid-morning in Europe and it appears that there is more concern in Geneva than in D.C. and Atlanta about the severity of a swine flu H1N1 pandemic.

From World Health Organization (WHO): 1 May 2009 -- The situation continues to evolve rapidly. As of 06:00 GMT, 1 May 2009, 11 countries have officially reported 331 cases of influenza A(H1N1) infection. The United States Government has reported 109 laboratory confirmed human cases, including one death. Mexico has reported 156 confirmed human cases of infection, including nine deaths. The following countries have reported laboratory confirmed cases with no deaths - Austria (1), Canada (34), Germany (3), Israel (2), Netherlands (1), New Zealand (3), Spain (13), Switzerland (1) and the United Kingdom (8).

The most recent information from Centers for Disease Control (CDC) is contained in a mortality / morbidity report directed at public health officials and physicians. It has a much less anxious tone. "The findings from this investigation (in a population known to be at low risk for severe disease from seasonal influenza) indicate that symptoms appear to be similar to those of seasonal influenza. The risk for severe disease among higher risk groups is not yet known."

The most frequently reported symptoms were cough, subjective fever, fatigue, headache, sore throat, runny nose, chills), and muscle aches. Each of these symptoms occurred in at least 80% of patients. Nausea, stomach ache, diarrhea, shortness of breath, or joint pain occurred in about half of the patients. Maximum temperatures ranged from 99 to 104 degrees, one patient (of 44) was briefly hospitalized.



Overall, there have been between 109 and 135 confirmed cases in the US - and only one death. The rate of new case reporting in the US seems to have stabilized and in the CDC report a graph of new case reporting dates would seem to support that conclusion (at least in the New York population where 45 cases were confirmed prior to 04/25/09 and only five have been since (despite an increase in testing).

Our recommendations are unchanged; we strongly recommend attention to hygeine, hand washing, avoidance of sick individuals and travel to Mexico. Certainly panic is not appropriate. We should know more over the next several days and as information becomes available, we will share our thoughts. Have a happy, safe and healthy weekend!

Comments / Posted by Scott W. Yates, MD, MBA, MS, FACP