Robot Prostate Surgery: More ED, Incontinence

Minimally invasive prostate surgery -- often performed using a high-tech robot -- carries a higher risk of incontinence and erectile dysfunction than does open surgery.

However, the newer technique cuts patients' hospital stays, requires far fewer blood transfusions, and carries less than half the risk of leaving behind scar tissue necessitating a second surgery.

The findings come from an analysis of outcomes for men with prostate cancer who chose treatment with radical prostatectomy -- surgery to remove the prostate. There are two basic kinds of prostatectomy: the tried-and-true open surgery improved over 20 years or minimally invasive surgery, a much newer technique.

Today, as many as 70% of minimally invasive prostatectomies are performed using a surgeon-controlled robot, Brigham and Women's Hospital urologist Jim C. Hu, MD, MPH, said at a news conference. This appears to be driven by direct-to-consumer marketing by hospitals that have purchased the robots, which cost up to $2 million.

But does minimally invasive prostatectomy really work as well as open surgery? To find out, Hu and colleagues analyzed prostate surgery outcomes for nearly 9,000 men whose records are in the Medicare-linked SEER database.

Importantly, open and minimally invasive surgery (both manual and robotic) were equally excellent at ridding men of prostate cancer.

But there were big differences between the two surgical choices in other outcomes. Minimally invasive surgery had several important advantages over open surgery:

One day shorter hospital stay (two days vs. three days)

Far less need for blood transfusion

Much less likely to leave scar tissue (anastomotic stricture), which often requires surgical correction

Fewer surgical complications

But minimally invasive surgery also had several important drawbacks compared with open surgery:

18 months after surgery, a higher rate of incontinence

18 months after surgery, a higher rate of erectile dysfunction

Nearly twice as many urinary and genital complications

"Outcomes of minimally invasive prostatectomy are not uniformly superior to the open approach," Hu said.

He said the technique has been oversold to patients. But he noted that doctors have had decades to learn the best techniques for open prostate surgery.

"Dissemination of surgical technique takes years to unfold," Hu said. "Our study needs to be repeated in the future when teaching of proper minimally invasive technique has had time to diffuse." The Hu study appears in the Oct. 14 issue of The Journal of the American Medical Association.

By Daniel J. DeNoon / WebMD Health News

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

Give Yourself a Boost

Beyond Flu Shots, Many Adults Forgo Vaccines That Could Prevent Potentially Lethal Illnesses

As the push gets under way to immunize Americans against swine flu and the seasonal flu, infectious-disease experts warn that many adults haven't received vaccinations for at least half a dozen other preventable diseases-some of which could put people who get influenza at even greater risk for complications and death.

Bacterial pneumonia is the most dangerous complication of the flu and a leading cause of death in previous flu pandemics. Yet only one in four adults under 65 who are considered by the Centers for Disease Control and Prevention to be at risk for the infection have been vaccinated against invasive pneumococcal disease, which causes bacterial pneumonia.

Adult-vaccination rates for other diseases also are dangerously low. Only half the people whom the CDC says should be vaccinated for whooping cough, which can also complicate the flu, have received the immunization. Those percentages are even lower for hepatitis B (32%), human papillomavirus (11%), which can lead to cervical cancer, and shingles (7%). Some adults need vaccinations because they never received them as children, or the immunity can fade over time. As people age, they also become more susceptible to infection. And some newer vaccines weren't available when many adults where children, while some have been improved on.

In all, more than 50,000 U.S. adults die from vaccine-preventable diseases annually-more than from breast cancer, AIDS, or traffic accidents. And hundreds of thousands of adults are sickened or suffer long-term problems from pneumococcal disease, meningitis, shingles and hepatitis, adding more than $10 billion annually to U.S. health-care costs.

"Vaccines have not been front and center in our national efforts for disease prevention as they should be," says Gregory A. Poland, director of the Mayo Clinic's vaccine-research group. "It's a collusion of ignorance-patients don't know to ask about vaccines, and physicians often don't have good mechanisms to screen patients and determine which vaccines they need."

A 2007 study by the CDC found that 78% of doctors either only occasionally ask or don't inquire at all about their patients' vaccination status. Doctors also reported that reimbursement for immunization is inadequate. While the federal vaccines-for-children program provides vaccines at no cost to underserved children, there is no national system to promote and monitor adult vaccination or pay for vaccines for those who can't afford them. Vaccines, which can range in price from $20 to nearly $300, often aren't covered or are only partly covered by insurance plans, including Medicare.

The National Vaccine Advisory Committee, which assesses federal immunization programs, is preparing several recommendations to improve vaccination rates and secure adequate federal funding for adult immunization. Vaccine-financing programs are also part of some health-reform proposals being considered by Congress. One proposal: a requirement that all insurance plans cover recommended vaccines for adults.

Unlike the flu shot, which is given annually and formulated to prevent specific strains of flu, adult vaccines are typically given once, with booster shots over time for some. And while children are typically followed by a pediatrician until they turn 18, "adults may see a lot of different doctors over their lifespan," which makes it harder to coordinate preventive care and keep track of which vaccinations have been received, says Carol Friedman, associate director for adult immunizations at the CDC's center for immunization and respiratory disease. Generally, if patients are unsure if they have been vaccinated, there is no harm in getting immunized again, or in receiving several shots at one doctor's visit.

A vaccine schedule for adults, updated annually, is available at CDC.gov/vaccines. The site also includes easy-to-understand vaccine fact sheets and an interactive quiz to help consumers determine which vaccines they need.

The CDC is urging state public health departments to encourage the use of the vaccine against pneumococcal disease, known as PSV, at the same time as vaccines for seasonal flu and the swine flu for those at risk. In addition to all adults over 65, those at risk include smokers and others aged 19 to 64 with asthma, heart disease, diabetes, or conditions that lower resistance to infection. Bacterial pneumonia has already been found in autopsies of 22 victims of swine flu who died in recent months, the CDC says.

A CDC national immunization survey conducted last year showed especially low rates for the vaccination for shingles, a reactivation of the childhood chickenpox virus. A vaccine was introduced three years ago, but only about 7% of adults over 60 who are recommended to get the vaccine have done so. Though not life threatening, shingles can cause a painful and disfiguring rash, and can involve nerves around the eye that can lead to blindness. Moreover, some patients experience severe nerve pain that can last for years, with little relief available from pain medications.

One barrier: The vaccine, which costs as much as $270, is covered by Medicare's part D drug benefit, not the Part B medical benefit. That means patients covered by the federal insurance program have to get a prescription from their doctor, take it to a pharmacy and then bring the vaccine back to their doctor for administration, unless they can find a drugstore-based clinic that will provide the vaccine on site.

Joan Ditcher, a New York City teacher, suffered excruciating pain after being diagnosed with shingles last fall at age 63, but says none of her doctors ever suggested the vaccine to her. "I believe in preventive care, as long as I'm aware of it," says Ms. Ditcher. "If I had known the vaccine was recommended for everyone my age, I would have gotten it." She has since received the vaccine, as shingles can recur, and convinced all of her friends to get it as well.

Only about half of adults have received the Tdap vaccine, which was licensed in 2005 as the first vaccine for adolescents and adults to combine a tetanus and diphtheria shot with pertussis, or whooping cough, which can cause violent coughing and pneumonia and presents a big risk when combined with influenza.

The CDC recommends that adults under 65 who have never received the Tdap vaccine substitute it for their next booster dose of tetanus, which should be received every 10 years. The most severe cases of disease and death linked to whooping cough have been in infants under six months of age, and the source of that infection is most often an older child or adult, so parents of newborns or women who plan to become pregnant are advised to get the vaccine.

Rates for vaccines against sexually transmitted diseases are also low. Only 11% of women between the ages of 19 and 26 have received the three-dose vaccine for human papillomavirus, or HPV, which prevents genital warts that can lead to cervical cancer. (The CDC's vaccine advisory committee is expected to vote at a meeting in Atlanta next week over whether to recommend that the vaccine be given to boys and young men as well.) The CDC also recommends that anyone who is not in a long-term, mutually monogamous sexual relationship and men who have sex with men to get a hepatitis B vaccination to prevent the infection that can cause liver cancer.

Making young adults more aware of vaccines is also crucial, experts say. A survey released this year by the National Foundation for Infectious Diseases, a nonprofit group funded by unrestricted grants from some vaccine makers, for example, shows only 49% of 18 to 26 year olds know that tetanus causes lockjaw, and that you should be vaccinated against it every 10 years.

Some patient advocacy groups are taking steps to raise awareness of vaccines for specific diseases, including Meningitis Angels (stompingoutmeningitis.com). The group was formed by Frankie Milley of Houston after her son Ryan died at 18 from bacterial meningitis, an infection that can lead to limb amputation, brain damage and death. Because it has been found to strike college students living in dormitories and frequenting crowded bars where smoking takes place, the CDC recommends that students get the meningococcal conjugate vaccine.

Leslie Meigs, a student at the University of St. Thomas in Houston, survived meningitis as a child but was left with chronic kidney disease that eventually required a transplant with a kidney donated by her father. She works with Ms. Milley's group.

"One of the things that young adults may not understand is this isn't a disease that you have and then go on normally with the rest of your life," says Ms. Meigs. "This is a disease that will leave you with after effects until the day you die."

From The Wall Street Journal by Laura Landro

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

Happiness

"Happiness is when what you think, what you say, and what you do are in harmony."

-- Mahatma Gandhi

Busted Fitness Myths

Think you know the facts about getting fit? You may be surprised to learn how many are really fiction.

It's easy to fall into the trap: A workout buddy passes along an exercise tip, and then you pass it on to several folks you know. One day, you're at the gym, and sure enough, you hear the same tip repeated, so you figure it must be true. But experts say that in the world of fitness, myths and half-truths abound – and some of them may be keeping you from getting the workout you need.

"Some myths are just harmless half-truths, but many others can actually be harmful," says professional triathlete and personal coach Eric Harr, author of The Portable Personal Trainer. "They can cause frustration in working out and sometimes even lead to injury," he notes.

One reason myths get started, says Harr, is that we all react to exercise a little differently. So what's true for one person may not be true for another.

"In this sense you sometimes have to find your own 'exercise truths' – the things that are true for you," says Harr.

That said, experts say there are also some fitness myths that just need busting, and the sooner the better!

To help put you on the path to a healthier, safer, and more enjoyable workout, WebMD got the lowdown from several top experts on what's true and what's not when it comes to exercise tips.

Fitness Myth No. 1: Running on a treadmill puts less stress on your knees than running on asphalt or pavement.

"Running is a great workout, but it can impact the knees -- and since it's the force of your body weight on your joints that causes the stress, it's the same whether you're on a treadmill or on asphalt," says Todd Schlifstein, DO, a clinical instructor at New York University Medical Center's Rusk Institute.

The best way to reduce knee impact, says Schlifstein, is to vary your workout.

"If you mix running with other cardio activities, like an elliptical machine, or you ride a stationary bike, you will reduce impact on your knees so you'll be able to run for many more years," says Schlifstein.

Fitness Myth No. 2: Doing crunches or working on an "ab machine" will get rid of belly fat.

Don't believe everything you hear on those late-night infomercials! Harr says that while an ab-crunching device might "help strengthen the muscles around your midsection and improve your posture," being able to "see" your abdominal muscles has to do with your overall percentage of body fat. If you don't lose the belly fat, he says, you won't see the ab muscles.

But can doing ab crunches help you to lose that belly fat? Experts say no.

"You can’t pick and choose areas where you’d like to burn fat," says Phil Tyne, director of the fitness center at the Baylor Tom Landry Health & Wellness Center in Dallas. So crunches aren't going to target weight loss in that area.

"In order to burn fat, you should create a workout that includes both cardiovascular and strength-training elements. This will decrease your overall body fat content," including the area around your midsection, he says.

Fitness Myth No. 3: An aerobic workout will boost your metabolism for hours after you stop working out.

This statement is actually true -- but the calorie burn is probably not nearly as much as you think!

Harr says that while your metabolism will continue to burn at a slightly higher rate after you finish an aerobic workout, the amount is not statistically significant. In fact, it allows you to burn only about 20 extra calories for the day. While there's a little bit more of a metabolic boost after strength training, he says, it's still marginal.

"It doesn't really count towards your caloric burn," he says.

Fitness Myth No. 4: Swimming is a great weight loss activity.

While swimming is great for increasing lung capacity, toning muscles, and even helping to burn off excess tension, Harr says the surprising truth is that unless you are swimming for hours a day, it may not help you lose much weight.

"Because the buoyancy of the water is supporting your body, you're not working as hard as it would if, say, you were moving on your own steam -- like you do when you run," says Harr.

Further, he says, it's not uncommon to feel ravenous when you come out of the water.

"It may actually cause you to eat more than you normally would, so it can make it harder to stay with an eating plan," he says.

Fitness Myth No. 5: Yoga can help with all sorts of back pain.

The truth is that yoga can help with back pain, but it's not equally good for all types.

"If your back pain is muscle-related, then yes, the yoga stretches and some of the positions can help. It can also help build a stronger core, which for many people is the answer to lower back pain," says Schlifstein.

But if your back problems are related other problems (such as a ruptured disc) yoga is not likely to help, he says. What's more, it could actually irritate the injury and cause you more pain.

If you do have back pain, get your doctor's OK before starting any type of exercise program.

Fitness Myth No. 6: If you're not working up a sweat, you're not working hard enough.

"Sweating is not necessarily an indicator of exertion," says Tyne. "Sweating is your body’s way of cooling itself."

It's possible to burn a significant number of calories without breaking a sweat: Try taking a walk or doing some light weight training.

Fitness Myth No. 7: As long as you feel OK when you're working out, you're probably not overdoing it.

One of the biggest mistakes people tend to make when starting or returning to an exercise program is doing too much too soon. The reason we do that, says Schlifstein, is because we feel OK while we are working out.

"You don't really feel the overdoing it part until a day or two later," he says.

No matter how good you feel when you return to an activity after an absence, Schlifstein says you should never try to duplicate how much or how hard you worked in the past. Even if you don't feel it at the moment, you'll feel it in time, he says -- and it could take you back out of the game again.

Fitness Myth No. 8: Machines are a safer way to exercise because you're doing it right every time.

Although it may seem as if an exercise machine automatically puts your body in the right position and helps you do all the movements correctly, that's only true if the machine is properly adjusted for your weight and height, experts say.

"Unless you have a coach or a trainer or someone figure out what is the right setting for you, you can make just as many mistakes in form and function, and have just as high a risk of injury, on a machine as if you work out with free weights or do any other type of nonmachine workout," says Schlifstein.

Fitness Myth No. 9: When it comes to working out, you've got to feel some pain if you're going to gain any benefits.

Of all the fitness rumors ever to have surfaced, experts agree that the "no pain-no gain" holds the most potential for harm.

While you should expect to have some degree of soreness a day or two after working out, Schlifstein says, that's very different from feeling pain while you are working out.

"A fitness activity should not hurt while you are doing it, and if it does, then either you are doing it wrong, or you already have an injury," he says.

As for "working through the pain," experts don't advise it. They say that if it hurts, stop, rest, and see if the pain goes away. If it doesn't go away, or if it begins again or increases after you start to work out, Schlifstein says, see a doctor.

From WebMD, By Colette Bouchez

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

PSA screens need more discussion

Physicians need to involve men more in the decision to undergo prostate-specific antigen (PSA) tests, concluded two studies and two editorials in Archives of Internal Medicine.

Clinicians strongly influence men's decisions to undergo PSA screening, but the conversations about screening fail to qualify as shared decision making because patients received more information about the pros than the cons, had limited knowledge of their importance, and were not routinely asked for their preferences.

In one study, researchers conducted a telephone survey of 375 men who had either undergone or discussed with clinicians PSA testing in the previous two years. Researchers assessed the character of the discussion, the patient's knowledge of prostate cancer and the importance of decision factors.

Almost 70% of patients discussed screening beforehand. Clinicians most often raised the idea of screening (64.6%), and 73.4% recommended PSA testing. Clinicians emphasized the pros of testing in 71.4% of discussions but addressed the cons in 32% of talks.

Researchers then asked the patients three questions to test their knowledge:

"Of every 100 men, about how many do you think will die of prostate cancer?"

"Of 100 men, about how many will be diagnosed as having prostate cancer at some time in their lives?"

"For every 100 times a PSA test result suggests the need for further testing, about how many times does it turn out to be cancer?"

Although 58% of patients reported they felt well-informed about PSA testing, 47.8% failed to correctly answer any of the three questions, and only 7.2% of respondents could correctly answer more than one.

Only 54.8% of subjects reported being asked for their screening preferences. The clinicians' recommendations were the only discussion characteristic associated with testing (odds ratio, 2.67; 95% CI, 1.08-6.58). "Indeed, few subjects sought second opinions," researchers wrote.

An editorial concluded the research was an important step in prompting discussion about the tradeoffs between overdiagnosis and treatment complications versus the benefits of reduced risk of prostate cancer-related mortality.

A second editorial chided, "Today's practice environment presents few incentives or support tools for those clinicians and patients who prefer a discussion rather than simply marking a checkbox for PSA on a laboratory requisition form." It also noted some physicians may not ask to screen beforehand, but instead piggyback PSA tests onto other bloodwork.

A second study aimed to support individual decision making by creating a model of the likely benefits and harms.

Researchers in Australia created a model for men aged 40, 50, 60, and 70 years at low, moderate and high risk for prostate cancer. A Markov model compared patients with and without annual PSA screening using a 20% relative risk in prostate cancer mortality as a best-case scenario. The model estimated numbers of biopsies, prostate cancers and deaths from prostate cancer per 1,000 men over 10 years and cumulated to age 85 years.

Benefits and harms vary substantially with age and familial risk, the model found. As an example, among 1,000 60-year-old men with low risk screened annually, 115 would undergo biopsy triggered by an abnormal PSA screen. Among screened men, 53 would be diagnosed with prostate cancer over 10 years, compared with 23 men diagnosed as having prostate cancer among 1,000 unscreened men.

Among screened men, 3.5 would die of prostate cancer over 10 years compared with 4.4 deaths in unscreened men. For every 1,000 men screened from 40 to 69 years of age, there would be 27.9 prostate cancer deaths and 639.5 deaths overall by age 85 years compared with 29.9 prostate cancer deaths and 640.4 deaths overall in unscreened men. Higher-risk men have more prostate cancer deaths but also incurred more prostate cancers diagnosed and related harms.

References:

Richard M. Hoffman, MD, MPH; Mick P. Couper, PhD; Brian J. Zikmund-Fisher, PhD; Carrie A. Levin, PhD; Mary McNaughton-Collins, MD, MPH; Deborah L. Helitzer, ScD; John VanHoewyk, PhD; Michael J. Barry, MD. Prostate Cancer Screening Decisions. Arch Intern Med. 2009;169(17):1611-1618.

Steven H. Woolf, MD, MPH; Alex Krist, MD, MPH. Shared Decision Making for Prostate Cancer Screening. Arch Intern Med. 2009;169(17):1557-1559.

Kirsten Howard, BSc(Hons), MAppSc, MPH, MHealthEcon, PhD; Alex Barratt, MBBS, MPH, PhD; Graham J. Mann, MBBS, PhD;Manish I. Patel, MBBS, MMed, FRACS, PhD. A Model of Prostate-Specific Antigen Screening Outcomes for Low- to High-Risk Men. Arch Intern Med. 2009;169(17):1603-1610.

Michael Pignone, MD, MPH. Weighing the Benefits and Downsides of Prostate-Specific Antigen Screening. Arch Intern Med. 2009;169(17):1554-1556.

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

Obesity Epidemic Increases, Mississippi Weighs In As Heaviest State

Adult obesity rates increased in 23 states and did not decrease in a
single state in the past year, according to F as in Fat: How Obesity
Policies Are Failing in America 2009, a report released today by the
Trust for America's Health (TFAH) and the Robert Wood Johnson Foundation
(RWJF). In addition, the percentage of obese or overweight children is
at or above 30 percent in 30 states.

"Our health care costs have grown along with our waist lines," said Jeff
Levi, Ph.D., executive director of TFAH. "The obesity epidemic is a big
contributor to the skyrocketing health care costs in the United States.
How are we going to compete with the rest of the world if our economy
and workforce are weighed down by bad health?"

Mississippi had the highest rate of adult obesity at 32.5 percent,
making it the fifth year in a row that the state topped the list. Four
states now have rates above 30 percent, including Mississippi, West
Virginia (31.2 percent), Alabama (31.1 percent) and Tennessee (30.2
percent). Eight of the 10 states with the highest percentage of obese
adults are in the South. Colorado continued to have the lowest
percentage of obese adults at 18.9 percent.

Adult obesity rates now exceed 25 percent in 31 states and exceed 20
percent in 49 states and Washington, D.C. Two-thirds of American adults
are either obese or overweight. In 1991, no state had an obesity rate
above 20 percent. In 1980, the national average for adult obesity was 15
percent. Sixteen states experienced an increase for the second year in a
row, and 11 states experienced an increase for the third straight year.

Mississippi also had the highest rate of obese and overweight children
(ages 10 to 17) at 44.4 percent. Minnesota and Utah had the lowest rate
at 23.1 percent. Eight of the 10 states with the highest rates of obese
and overweight children are in the South. Childhood obesity rates have
more than tripled since 1980.

"Reversing the childhood obesity epidemic is a critical ingredient for
delivering a healthier population and making health reform work," said
Risa Lavizzo-Mourey, M.D., M.B.A., RWJF president and CEO. "If we can
prevent the current generation of young people from developing the
serious and costly chronic conditions related to obesity, we can not
only improve health and quality of life, but we can also save billions
of dollars and make our health care systems more efficient and
sustainable."

The F as in Fat report contains rankings of state obesity rates and a
review of federal and state government policies aimed at reducing or
preventing obesity. Some additional key findings from F as in Fat 2009
include:

-- The current economic crisis could exacerbate the obesity epidemic.
Food prices, particularly for more nutritious foods, are expected to
rise, making it more difficult for families to eat healthy foods. At the
same time, safety-net programs and services are becoming increasingly
overextended as the numbers of unemployed, uninsured and underinsured
continue to grow. In addition, due to the strain of the recession, rates
of depression, anxiety and stress, which are linked to obesity for many
individuals, also are increasing.

-- Nineteen states now have nutritional standards for school lunches,
breakfasts and snacks that are stricter than current USDA requirements.
Five years ago, only four states had legislation requiring stricter
standards.

-- Twenty-seven states have nutritional standards for competitive foods
sold a la carte, in vending machines, in school stores or in school bake
sales. Five years ago, only six states had nutritional standards for
competitive foods.

-- Twenty states have passed requirements for body mass index (BMI)
screenings of children and adolescents or have passed legislation
requiring other forms of weight-related assessments in schools. Five
years ago, only four states had passed screening requirements.

-- A recent analysis commissioned by TFAH found that the Baby Boomer
generation has a higher rate of obesity compared with previous
generations. As the Baby Boomer generation ages, obesity-related costs
to Medicare and Medicaid are likely to grow significantly because of the
large number of people in this population and its high rate of obesity.
And, as Baby Boomers become Medicare-eligible, the percentage of obese
adults age 65 and older could increase significantly. Estimates of the
increase in percentage of obese adults range from 5.2 percent in New
York to 16.3 percent in Alabama.

Key report recommendations for addressing obesity within health reform
include:

-- Ensuring every adult and child has access to coverage for preventive
medical services, including nutrition and obesity counseling and
screening for obesity-related diseases, such as type 2 diabetes;

-- Increasing the number of programs available in communities, schools,
and childcare settings that help make nutritious foods more affordable
and accessible and provide safe and healthy places for people to engage
in physical activity; and

-- Reducing Medicare expenditures by promoting proven programs that
improve nutrition and increase physical activity among adults ages 55 to
64.

The report also calls for a National Strategy to Combat Obesity that
would define roles and responsibilities for federal, state and local
governments and promote collaboration among businesses, communities,
schools and families. It would seek to advance policies that

-- Provide healthy foods and beverages to students at schools;

-- Increase the availability of affordable healthy foods in all
communities;

-- Increase the frequency, intensity, and duration of physical activity
at school;

-- Improve access to safe and healthy places to live, work, learn, and
play;

-- Limit screen time; and

-- Encourage employers to provide workplace wellness programs.

Source: Trust for America's Health

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

Sorting Fact From Fiction on Health Care

In recent town-hall meetings, President Barack Obama has called for a national debate on health-care reform based on facts. It is fact that more than 40 million Americans lack coverage and spiraling costs are a burden on individuals, families and our economy. There is broad consensus that these problems must be addressed. But the public is skeptical that their current clinical care is substandard and that no government bureaucrat will come between them and their doctor. Americans have good reason for their doubts—key assertions about gaps in care are flawed and reform proposals to oversee care could sharply shift decisions away from patients and their physicians.

Consider these myths and mantras of the current debate:

• Americans only receive 55% of recommended care. This would be a frightening statistic, if it were true. It is not. Yet it was presented as fact to the Senate Health and Finance Committees, which are writing reform bills, in March 2009 by the Agency for Healthcare Research and Quality (the federal body that sets priorities to improve the nation's health care).

The statistic comes from a flawed study published in 2003 by the Rand Corporation. That study was supposed to be based on telephone interviews with 13,000 Americans in 12 metropolitan areas followed up by a review of each person's medical records and then matched against 439 indicators of quality health practices. But two-thirds of the people contacted declined to participate, making the study biased, by Rand's own admission. To make matters worse, Rand had incomplete medical records on many of those who participated and could not accurately document the care that these patients received.

For example, Rand found that only 15% of the patients had received a flu vaccine based on available medical records. But when asked directly, 85% of the patients said that they had been vaccinated. Most importantly, there were no data that indicated whether following the best practices defined by Rand's experts made any difference in the health of the patients.

In March 2007, a team of Harvard researchers published a study in the New England Journal of Medicine that looked at nearly 10,000 patients at community health centers and assessed whether implementing similar quality measures would improve the health of patients with three costly disorders: diabetes, asthma and hypertension. It found that there was no improvement in any of these three maladies.

Dr. Rodney Hayward, a respected health-services professor at the University of Michigan, wrote about this negative result, "It sounds terrible when we hear that 50 percent of recommended care is not received, but much of the care recommended by subspecialty groups is of a modest or unproven value, and mandating adherence to these recommendations is not necessarily in the best interest of patients or society."

• The World Health Organization ranks the U.S. 37th In the world in quality. This is another frightening statistic. It is also not accurate. Yet the head of the National Committee for Quality Assurance, a powerful organization influencing both the government and private insurers in defining quality of care, has stated this as fact.

The World Health Organization ranks the U.S. No. 1 among all countries in "responsiveness." Responsiveness has two components: respect for persons (including dignity, confidentiality and autonomy of individuals and families to make decisions about their own care), and client orientation (including prompt attention, access to social support networks during care, quality of basic amenities and choice of provider). This is what Americans rightly understand as quality care and worry will be lost in the upheaval of reform. Our country's composite score fell to 37 primarily because we lack universal coverage and care is a financial burden for many citizens.

• We need to implement "best practices." Mr. Obama and his advisers believe in implementing "best practices" that physicians and hospitals should follow. A federal commission would identify these practices.

On June 24, 2009, the president appeared on "Good Morning America" with Diane Sawyer. When Ms. Sawyer asked whether "best practices" would be implemented by "encouragement" or "by law," the president did not answer directly. He said that he was confident doctors "want to engage in best practices" and "patients are going to insist on it." The president also said there should be financial incentives to "allow doctors to do the right thing."

There are domains of medicine where a patient has no control and depends on the physician and the hospital to provide best practices. Strict protocols have been developed to prevent infections during procedures and to reduce the risk of surgical mishaps. There are also emergency situations like a patient arriving in the midst of a heart attack where standardized advanced treatments save many lives.

But once we leave safety measures and emergency therapies where patients have scant say, what is "the right thing"? Data from clinical studies provide averages from populations and may not apply to individual patients. Clinical studies routinely exclude patients with more than one medical condition and often the elderly or people on multiple medications. Conclusions about what works and what doesn't work change much too quickly for policy makers to dictate clinical practice.

An analysis from the Ottawa Health Research Institute published in the Annals of Internal Medicine in 2007 reveals how long it takes for conclusions derived from clinical studies about drugs, devices and procedures to become outdated. Within one year, 15 of 100 recommendations based on the "best evidence" had to be significantly reversed; within two years, 23 were reversed, and at 5 1/2 years, half were contradicted. Americans have witnessed these reversals firsthand as firm "expert" recommendations about the benefits of estrogen replacement therapy for postmenopausal women, low fat diets for obesity, and tight control of blood sugar were overturned.

Even when experts examine the same data, they can come to different conclusions. For example, millions of Americans have elevated cholesterol levels and no heart disease. Guidelines developed in the U.S. about whom to treat with cholesterol-lowering drugs are much more aggressive than guidelines in the European Union or the United Kingdom, even though experts here and abroad are extrapolating from the same scientific studies. An illuminating publication from researchers in Munich, Germany, published in March 2003 in the Journal of General Internal Medicine showed that of 100 consecutive patients seen in their clinic with high cholesterol, 52% would be treated with a statin drug in the U.S. based on our guidelines while only 26% would be prescribed statins in Germany and 35% in the U.K. So, different experts define "best practice" differently. Many prominent American cardiologists and specialists in preventive medicine believe the U.S. guidelines lead to overtreatment and the Europeans are more sensible. After hearing of this controversy, some patients will still want to take the drug and some will not.

This is how doctors and patients make shared decisions—by considering expert guidelines, weighing why other experts may disagree with the guidelines, and then customizing the therapy to the individual. With respect to "best practices," prudent doctors think, not just follow, and informed patients consider and then choose, not just comply.

• No government bureaucrat will come between you and your doctor. The president has repeatedly stated this in town-hall meetings. But his proposal to provide financial incentives to "allow doctors to do the right thing" could undermine this promise. If doctors and hospitals are rewarded for complying with government mandated treatment measures or penalized if they do not comply, clearly federal bureaucrats are directing health decisions.

Further, at the AMA convention in June 2009, the president proposed linking protection for physicians from malpractice lawsuits if they strictly adhered to government-sponsored treatment guidelines. We need tort reform, but this is misconceived and again clearly inserts the bureaucrat directly into clinical decision making. If doctors are legally protected when they follow government mandates, the converse is that doctors risk lawsuits if they deviate from federal guidelines—even if they believe the government mandate is not in the patient's best interest. With this kind of legislation, physicians might well pressure the patient to comply with treatments even if the therapy clashes with the individual's values and preferences.

The devil is in the regulations. Federal legislation is written with general principles and imperatives. The current House bill H.R. 3200 in title IV, part D has very broad language about identifying and implementing best practices in the delivery of health care. It rightly sets initial priorities around measures to protect patient safety. But the bill does not set limits on what "best practices" federal officials can implement. If it becomes law, bureaucrats could well write regulations mandating treatment measures that violate patient autonomy.

Private insurers are already doing this, and both physicians and patients are chafing at their arbitrary intervention. As Congress works to extend coverage and contain costs, any legislation must clearly codify the promise to preserve for Americans the principle of control over their health-care decisions.

By Drs. Jerome Groopman and Pamela Hartzband for the Wall Street Journal. Dr. Groopman, a staff writer for the New Yorker, and Dr. Hartzband are on the staff of Beth Israel Deaconess Medical Center in Boston and on the faculty of Harvard Medical School.

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

'Macho' men visit doctors less - and die younger. Are these related?

It's no secret that men don't like to go to the doctor, but new research finds they're especially likely to stay home if they're big on being macho.

Middle-aged men who are most devoted to traditional beliefs about masculinity are half as likely as other men to get routine medical care, researchers report.

It's not clear whether feelings about masculinity directly make men avoid doctor visits; the study only indicates that a cause-and-effect link might exist. Nor do researchers know what this might mean for men's health.

Still, the findings suggest that "we could help men's health if we could dismantle this idea that manhood and masculinity is about being invulnerable, not needing help and not showing pain," said study author Kristen W. Springer, an assistant professor of sociology at Rutgers, the
State University of New Jersey.

Previous research has suggested that "men are less likely to go to the doctor than women, across the board," Springer said - a notion she finds surprising because men are wealthier overall, potentially giving them better access to medical care.

Springer and a colleague launched their study to determine the role that ideas about masculinity play in the decisions men make about their health care.

Springer said she defines masculinity as a "stereotypical, old-school, John Wayne- and Sylvester Stallone-style" approach to life.

The researchers examined the results of surveys taken in 2004 by 1,000 white, middle-aged men in Wisconsin. The men answered questions about their beliefs regarding masculinity and disclosed whether they'd gotten recommended annual physicals, prostate checks and flu shots.

After adjusting the results to reduce the chance they would be thrown off by such things as a high number of married participants, researchers found that men who were the highest believers in masculine standards were 50% less likely to get the recommended care than other men.

Springer was unable to provide statistics about the percentage of men in each group who got the recommended care. Overall, though, fewer than half of all men did, according to the study.

There was one exception to the rule: Blue-collar workers who had a high attachment to masculinity were more likely to get the recommended health care.

The study has limitations. All participants were white and all had completed high school. And Springer said unanswered questions remain, such as whether spouses play a role through "support or nagging." The findings were to be presented Monday at the American Sociological
Association annual meeting in San Francisco.

Howard S. Friedman, a professor of psychology at the University of California at Riverside, said his research has found that less masculine men live longer than masculine men. But the new study doesn't show anything like that because it doesn't examine long-term effects on health, he said.

As for the gap between men and women when it comes to living longer, he said, "it would be a stretch, going beyond the data, to link it closely to men's increased mortality risk as compared to women."

By Randy Dotinga, HealthDay, USA Today

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

H1N1 is back

H1N1 Swine Flu has killed at least four Dallas County residents in the past month.

Of the four known deaths, three occurred in people who had other medical problems (their ages were 3, 37 and 52 years). However, an 11 - year old girl who died earlier this week was previously healthy. We have identified two cases of H1N1 influenza this week. Both patients are being treated and are doing well.

The H1N1 vaccine should be available in the next few weeks and as soon as we receive vaccine, we will contact patients to schedule administration. For more information about H1N1 as well as additional preventive measures, please see this list of posts.

Have a safe weekend!

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

Saving Your Bones: Hard Choices

Osteoporosis Drugs Prevent Fractures, but Patients Worry About Side Effects; Weighing the Risks.

Osteoporosis has haunted my family for generations, as it has many other families.

My great-grandmother was bent nearly horizontal from collapsed vertebrae. My grandmother lost a foot in height as her spine deteriorated, and broke her hip just pushing a grocery cart. I made her a new backbone out of papier-mâché when I was 4.

My mother did everything she could to avoid the family curse, but she also suffered painful collapsed vertebrae. All three women died, directly or indirectly, as a result of osteoporosis.

That was before the bone-building drugs called bisphosphonates became widely available in the mid-1990s. Thanks in part to them, the number of hip fractures has dropped significantly in the U.S. and Canada in recent years.

Osteoporosis remains a serious health problem for the 10 million Americans who have it and the 34 million who are at risk due to low bone mass; 80% of sufferers are women. It's estimated that one half of women and one-quarter of men over age 50 will suffer an osteoporosis-related fracture.

But reports of scary side effects from bisphosphonates-including Fosamax, Actonel and Boniva-are circulating on the Internet and in medical journals. Hundreds of lawsuits allege that the drugs cause a rare condition in which part of the jaw bone dies. The first case to be tried against Merck & Co.'s Fosamax ended in a hung jury last week in federal court in New York City. And some critics say the drugs-with sales of $8.3 billion a year in the U.S.-are being oversold to women who may never need them.

All that leaves women facing a difficult dilemma: Powerful osteoporosis drugs known to prevent future debilitating injuries are also suspected of increasing the risk for other terrible conditions. Balancing the risks and benefits is different for every woman, and depends on factors such as genetic history, diet and lifestyle. Figuring out how to proceed also requires having a very careful discussion with a qualified physician.

A good place to start is with your family tree. Having a parent with osteoporosis raises your own risk significantly. Caucasians, Asians and Hispanics also have higher rates of osteoporosis than African-Americans. So far, scientists have identified 15 related genes-but there isn't likely to be a predictive genetic test anytime soon.

That's because environmental factors also play a big role. The more bone you build up during the peak building years before age 30, the more reserves you'll have when net bone loss sets in. For women, that happens very rapidly after menopause when estrogen levels decline. Men lose bone far more slowly, although hormone-deprivation drugs for prostate cancer can also set them up for osteoporosis, as can a very strong hereditary load.

A diet rich in calcium (from dairy products and vegetables), plenty of exposure to vitamin D and weight-bearing exercise all help to build strong bones. Too little of those can weaken them, as can smoking, drinking alcohol, and a taking a variety of medications, including corticosteroids, anticonvulsants and antidepressants. Excessive dieting and exercising and being very thin-with a body-mass index of less than 20-can also leave your bones with little reserve. Being obese actually lowers your risk, though it can overstress your joints.

But some people can do everything right and still develop osteoporosis if they have a strong genetic predisposition.

A bone-mineral-density test can give you one indication of how strong your bones are. Women with several risk factors should have one at menopause; or at least at age 65. The most common such test, called a DEXA (for dual-energy X-ray absorptiometry) is quick and painless and measures the amount of bone in your hip, spine or wrist. Results, called T-scores, compare that density with an average peak at age 30.

A T-score of minus 2.5 or below indicates osteoporosis. A T-score between minus 1 and minus 2.4 is considered osteopenia-meaning low bone density but not full-blown osteoporosis.

You and your doctor can also assess your risk by using an online tool developed by the World Health Organization called FRAX, for Fracture Assessment Risk Tool. (www.shef.ac.uk/frax) It asks your sex, age, weight, height, hip-bone density and factors such as smoking, drinking, and parental hip fractures. It computes your chances of suffering a major bone fracture in the next 10 years.

What to do with that information is still somewhat controversial. "If you already have severe osteoporosis, you don't need a FRAX score to tell you you need treatment," says Bess Dawson-Hughes, director of the Bone Metabolism Lab at Tufts University, who has advised many of the drug makers. "Where we have struggled is what to do with that large group of healthy people who have low bone mass."

The National Osteoporosis Foundation's latest guidelines say that women who have a 3% risk of developing a hip fracture or 20% risk of other major fracture in the next 10 years are candidates for treatment, on cost-effectiveness grounds. In studies of older women with osteoporosis, Fosamax has been found to reduce the chance of hip and spine fractures as much as 50% . But it's less clear to what extent such drugs can prevent osteopenia from becoming osteoporosis.

Experts say that individual patients should never be treated based on T-scores or FRAX probabilities alone. Many other considerations apply.

"You need to consider the unique characteristics of this lady in front of you," says Ethel Siris, director of the Toni Stabile Osteoporosis Center at Columbia Presbyterian Medical Center, who has also consulted for the drug makers. For example, a 50-year-old woman with osteopenia may not be a candidate for treatment based on her FRAX alone. But if she falls a lot and her mother suffered spinal fractures, which the FRAX doesn't ask about, it may make sense to treat her for a few years and see how her bone density does, Dr. Siris says. Meanwhile, a 70-year-old who has the same T-score probably started out with better bone density, but she has had 20 more years for her bone architecture to erode, so her bones are more fragile, even though they weigh the same.

The official guidelines also don't take into account potential side effects of the bisphosphonates, which are also highly individual. Gastrointestinal upsets are the most common; the oral medications aren't recommended for patients who can't sit upright for at least a half-hour because these drugs can irritate the esophagus. Gastro-esophageal reflux disease (GERD) can make such discomfort worse. A woman with severe GERD might fare better on Reclast, a once-a-year injection of bisphosphonate.

Some patients have also reported severe bone and muscle pain while taking bisphosphonates. The Food and Drug Administration alerted doctors last year that they might see this and consider discontinuing the drugs at least temporarily. Who is most affected and how long it lasts seems unpredictable. "I treat a gazillion patients and I see this rarely," says Dr. Siris. "When I do, we stop and re-evaluate."

Cases of osteonecrosis of the jaw (ONJ)-in which parts of bone become exposed during dental work and don't heal-are more serious but very rare. No one knows the exact incidence. Estimates range from 1 in 1,000 to 1 in 100,000 patients taking bisphosphonates for osteoporosis. (It's far more common in cancer patients on much higher doses.) Merck and other manufacturers say there is no evidence that the drugs cause ONJ at doses used for osteoporosis, but some dentists have become wary of doing invasive dental work on women taking bisphosphonates.

"We often advise patients who need extensive, invasive dental work to get that done first, then start the drugs and the issue disappears," says Ian Reid, a professor at the University of Auckland in New Zealand who has written on biosphosphonate safety.

A few doctors have reported unusual fractures of the thigh bone in women taking bisphosphonates for many years. One theory is that because the drugs inhibit the breakdown of old bone, they may be maintaining bone that is unusually brittle. Here too, the incidence seems extremely rare and the link remains unproven. But experts agree that it warrants further study-and that patients and doctors should investigate any unusual thigh pain which has preceded several of the fractures.

On balance, most experts say that women with confirmed osteoporosis face a much higher risk of fractures if they don't treat their condition than if they do. "These horrible cases are incredibly rare, whereas hip fractures are not rare in the aging population and they can kill you," says Dr. Siris. She notes that there are still many unknowns about drugs, including how long it is safe for women to stay on them. Many doctors are using them with patients only about five years at a time and then re-evaluating.

Other osteoporosis drugs on the market work differently and carry different risks. Evista (raloxifene) acts on estrogen receptors and can cut the risk of breast cancer as well as spinal fractures in some women, although it doesn't prevent hip fractures. Forteo (teriparatide) is a daily injection for women with severe osteoporosis, but has been linked with bone malignancies in rats. Last month an advisory panel recommended that the FDA approve denosumab, a biological agent that blocks the production of osteoclasts that break down bone. It would be a twice-yearly injection.

Estrogen-replacement therapy can also help women postpone the rapid loss of bone mass that occurs after menopause. It's no longer recommended for bone protection alone-in part because of the added risk of heart disease and breast cancer found in older women in the Women's Health Initiative studies. But the risk-benefit profile seems more favorable for younger women who want relief from menopausal symptoms like hot flashes. "If you hate your life without estrogen, you can go back on it and that's your bone-loss drug as well," says Dr. Siris.

Some clinics urge women to fight osteoporosis with lifestyle changes rather than pharmaceuticals. Many experts agree that sufficient calcium (at least 1,200 mg per day from food or supplements) and vitamin D (800 to 1,000 IUs per day) and weight-bearing exercise (at least 30 minutes, three times a week) are critical for building and maintaining strong bones, but they may not be sufficient for reversing serious bone loss once it's set in.

All camps agree that the very best way to strong bones is to build them well to begin with. Nearly 90% of bone mass in females is built by age 18, yet few adolescent girls are getting the recommended amounts of calcium and vitamin D.

By: Melinda Beck
From: The Wall Street Journal. Health Journal - September 15, 2009

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

Selling out doctors to pay off lawyers

Civil justice reform, which is sometimes referred to as “tort reform,” is not addressed in any health reform bill now being considered by Congress. As a matter of fact, civil justice reform is rarely being discussed even though it should be a critical component of every discussion and in every legitimate health reform bill.

Physicians understand its importance. And so do the American people. Many are beginning to wonder why it’s not in any bill.

Howard Dean, former chairman of the Democratic National Committee, at a town hall meeting in Virginia last week said, “Tort reform is not in the bill because the people who wrote it did not want to take on the trial lawyers. And, that is the plain and simple truth.”

Unfortunately, the “plain and simple truth” is that Democratic leaders in Congress and President Obama are selling out the doctors to pay off the trial lawyers.

In a recent poll, 90 percent of physicians agreed that health reform will not succeed in bringing about substantive reform without addressing tort reform. Sermo, an online community of over 100,000 physicians, reports that while reasonable people might disagree on the specifics of tort reform, the fundamental principle remains that defensive medicine is a byproduct of the current tort system.

The “plain and simple truth” is that leaving the tort system “as is” ignores more than $200 billion in potential savings annually in health care. If the fundamental driving force behind any national health reform proposal is improving care and reducing costs, tort reform should be contained in every rational approach to health reform.

Defensive medicine is one of the largest contributors to wasteful spending, and it can manifest in many forms: unnecessary CT scans, x-rays, MRIs, cardiac testing and inappropriate hospital admissions. A 2005 survey in the Journal of the American Medical Association found that 93 percent of doctors reported practicing defensive medicine. These unnecessary and expensive tests and procedures are not ordered to advance the care and treatment of a patient or help the physician diagnose a medical problem. These tests and procedures are ordered exclusively to protect a physician from a potential and likely frivolous lawsuit.

In a recent speech before the American Medical Association, even President Obama said that doctors shouldn’t “feel like they are constantly looking over their shoulder for fear of lawsuits.” The president recognized that defensive medicine is “a real issue” but there is nothing in the bill to protect physicians from frivolous lawsuits. And, there is nothing in the bill to help stop defensive medicine.

While the White House and the Democratic leaders in Congress don’t want “to take on the trial lawyers,” they are apparently willing to fight with the doctors, the hospitals, the drug companies, the health insurance industry and even the American people on health reform. But they feel compelled to placate to the trial lawyers? Protecting trial lawyers at the expense of physicians is not in the best way to address health reform and it is not in the best interest of the American people.

At the Center for Health Transformation, we have developed several solutions which would advance patient safety and provide for fair and effective compensation for individuals who have legitimate claims. Our solutions establish accountability and encourage the disclosure of adverse medical events so future medical errors can be avoided.

For example, we believe that physicians should be shielded from liability if they demonstrate the use of clinical best practices in the care and treatment of patients. Shielding physicians from liability when they use best practices would reduce defensive medicine and minimize the loss of competent health professionals driven out by the high cost of litigation insurance.

We also support the creation of specialized health courts to address medical malpractice cases as a rational civil justice reform. Even some Democrats have rallied around the health court solution. Former Sen. Bill Bradley (D-N.J.), in a recent New York Times column, said “Malpractice tort reform can be something as commonsensical as the establishment of medical courts – similar to bankruptcy or admiralty courts – with special judges to make determinations in cases brought by parties claiming injury.”

We believe it’s time to stop selling out the doctors to pay off the trial lawyers. The president must include civil justice reform in any successful health reform proposal.

Former House Speaker Newt Gingrich is the founder of the Center for Health Transformation. Wayne Oliver is director of the Center’s civil justice reform project.

By: Newt Gingrich and Wayne Oliver

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

Australian Humor

Today's post is just for fun, we hope you enjoy it and have a great weekend!

Two traffic patrol officers in Newcastle Australia were clocking motorists with a hand-held radar device. As a suspect car topped the hill, the radar recorded a speed of 800 km/h (500 mph). The officers' confusion was short-lived as the thurdering roar of a low-flying RAAF Boeing F-18 Hornet soared over their heads. Back at the station, the furious Area Commander fired off an email to his counterpart at the nearby Williamtown air base.

The reply:

"Thank you for your message, which allows us to complete the file on this incident. You may be interested to know that the tactical computer on the Hornet had detected the presence of, and subsequently locked onto, your hostile radar equipment and automatically sent a jamming signal back to it.

Furthermore, an air-to-ground missle aboard the fully armed aircraft had automatically locked onto your equipment.

Fortunately, the pilot flying the Hornet recognized the situation for what it was, and was able to override the automated defence system before the missle was launched and you hostile radar installation was destroyed.

Thank you for your enquiry."

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