January 25, 2013 | 3:15 pm

Newsflash: Smoking is Very Unhealthy

Posted by Albert Fuchs, M.D.

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Image credit
Wikimedia commons

I have shocking news. Smoking is very very bad for you.

In 1964 the US Surgeon General issued a report summarizing the known adverse health effects of smoking. At that time about 40% of American adults smoked. A widespread campaign followed informing Americans about the link between smoking and lung cancer, emphysema, stroke, and heart attacks. Federal law required the placement of health warnings on cigarette packages, and school children all learned about the adverse health effects of smoking.

By 2010 the prevalence of smoking decreased to 19% of American adults, mostly because of more people quitting (rather than fewer people starting). But from 2004 to 2010 the prevalence of smoking has changed little. We seem to have reached a steady state, a nadir of smoking despite the now well-known health hazards. And while smokers were much more representative of the general population in the 1960s, they are now disproportionately poor and less educated. Current smokers are also on average younger than non-smokers, since so many smokers quit as they get older.

This week the New England Journal of Medicine (NEJM) published two studies that attempted to quantify the differences in longevity between smokers and non-smokers. The studies followed hundreds of thousands of men and women and compared the information about their smoking status to their longevity and cause of death.

The results were fairly dramatic. On average, those who never smoked live over 10 years longer than those who continue to smoke their whole lives. For those between 25 and 79 years old, the death rate for smokers is three times that of those who never smoked. Those who quit also did much better than those who didn’t. Those who quit between the ages of 25 and 34 lived 10 years longer than those who continued smoking, almost reaching the longevity of those who never smoked. The benefit of quitting decreased with increasing age, but never disappeared. Smokers who quit between the ages of 55 and 64 still lived 4 years longer than those who kept smoking.

My regular readers will recognize that these are not randomized studies, and they therefore deserve some skepticism. That’s true. One study was controlled for alcohol use, educational level, and body mass index, but one can easily imagine other confounding factors (poverty, poor access to health care) that may be more prevalent among smokers and independently increase the risk of death. So we can’t be certain that the effect of smoking is as large as the study suggests. Still, the studies add to a mountain of evidence that has already established the risk of smoking. And a randomized study will never be done, so we will never be able to measure the risk exactly.

The bottom line is that smoking is likely to cut your life short. Quitting at any age has benefits. Sooner is better.

The author of an accompanying editorial in the same NEJM issue concludes with this concern.

Because smoking has become a stigmatized behavior concentrated among persons of low social status, it risks becoming invisible to those who set health policies and research priorities. Yet, the need for greater attention to the policies known to reduce the prevalence of smoking remains urgent. As former Australian Health Minister Nicola Roxon has said, “We are killing people by not acting.”

But the increasing “invisibility” and disenfranchisement of smokers seems to me inevitable. For half a century we have very successfully educated people about the risks of smoking. We have waged a campaign that has made it clear that smoking is hazardous and we have tried to make it uncool. We cannot simultaneously applaud our important success while being surprised that those most resistant to the message are those whom information and solid judgment are least likely to reach.

All diseases that are predominantly acquired through behaviors, like HIV or cervical cancer, follow the same pattern over time. As education about prevention of the disease spreads, those who have access to information and value their health will stop contracting the disease. A generation later those who are still engaging in the risky behaviors are very difficult to reach. Few problems are more intractable than people in free societies choosing to harm themselves.

Further progress in decreasing the prevalence of smoking is likely to be incremental and slow. I suspect further attempts at addressing this problem through policy will involve tradeoffs, not solutions.

Learn more:

Smokers Lose 10-Plus Years of Life, Studies Find (Wall Street Journal)
Quitting smoking prolongs life at any age (LA Times)
Putting a Number on Smoking’s Toll (NY Times)
21st-Century Hazards of Smoking and Benefits of Cessation in the United States (NEJM article)
50-Year Trends in Smoking-Related Mortality in the United States (NEJM article)
New Evidence That Cigarette Smoking Remains the Most Important Health Hazard (NEJM editorial)

Tangential Miscellany

Seven years and over 300 posts ago I decided to start writing a weekly health news blog. Since then my posts have been republished in half a dozen publications, started some fascinating debates, and I hope educated and stimulated you. Thank you for reading. I promise to try not to bore you in the next seven years.

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

January 18, 2013 | 12:40 pm

Curing Clostridium difficile with, um, Feces

Posted by Albert Fuchs, M.D.

Electron micrograph of C.
dif. bacteria. Image credit:
CDC PHIL(6260) /
Louis S. Wiggs

[This post is grosser than most. You may not want to read it over lunch.]

Last year I warned that Clostridium difficile (C. dif.) infections are becoming more common.

C. dif. is a bacterium that infects the colon causing severe, sometimes life-threatening, diarrhea. C. dif. infection is frequently a complication of antibiotic use. Antibiotics can kill the normal bacteria in the colon and establish an opportunity for C. dif. to proliferate. After a course of antibiotics, a person can remain susceptible for a few months, and subsequent exposure to C. dif., usually in a healthcare setting, can lead to infection.

The mainstay of C. dif. treatment is more antibiotics, typically vancomycin or metronidazole. But these antibiotics don’t always work, and in many cases the C. dif. infection is not eradicated and the diarrhea recurs.

For over 50 years investigators have suspected that restoring normal gut bacteria could treat C. dif. infection. In 1950s the bacterium C. dif. had not yet been isolated, but the severe colon infection that sometimes followed antibiotic use was well known. In 1958, physicians in Denver treated patients with C. dif. colitis with enemas containing feces from healthy people. They reported that their patients rapidly and dramatically improved and urged further study of this treatment.

Since then, antibiotic treatment for C. dif. was discovered, and the idea of curing C. dif. by restoring normal bacteria languished, mostly because the thought of treating a patient by giving him feces is aesthetically so unappealing. Nevertheless as C. dif. became more prevalent in recent years, and as antibiotic treatments became less effective, many gastroenterologists have resorted in desperation to treating these very sick patients with donated feces, either by enema, or through a colonoscope, or through a tube inserted through the nose to the small intestine. Invariably the success rates were extremely high, but this treatment never gained legitimacy, partially because of the lack of a rigorous trial comparing it to accepted antibiotic treatment, and partially because of the enormous yuck factor.

This week the New England Journal of Medicine published online a study that should convince the skeptics, if not the squeamish. Researchers in the Netherlands randomized patients with C. dif. infection who had already failed one course of antibiotic treatment. The patients were randomized into three groups. One group received the standard antibiotic treatment of vancomycin for 14 days. A second group received vancomycin for 14 days followed by a solution that flushes out the intestines by causing diarrhea (similar to a colonoscopy preparation). The third group received vancomycin for 4 days, the solution that flushes out the intestines, and then an infusion of feces through a tube inserted through their nose into the small intestine.

The research protocol made many strides in minimizing the unpleasantness of the stool infusion, and patients tolerated it very well. The infused “material” was provided by anonymous donors who were screened for infectious diseases. I’ll spare you the details of how the donated material was prepared, but the very curious can read the NY Times article about this study. Suffice it to say that the patients don’t see the infused solution. They only experience a plastic tube in their nose.

The results were quite dramatic. In fact, the study was stopped early because the differences between groups were so great. 81% of the patients receiving the feces infusion were cured after the first infusion, and most of the rest were cured with a second. In the antibiotic group about a third were cured, and in the group receiving vancomycin followed by the intestinal flushing solution, only about a quarter were cured. Many of the patients receiving antibiotics requested the feces infusion after the trial ended.

This should convince physicians and patients that if a first course of antibiotic treatment has failed, fecal infusion is a rational next step. It is hoped that eventually researchers will find and culture the bacteria that are responsible for inhibiting the growth of C. dif. so that eventually patients can swallow capsules of live cultured bacteria, eliminating the need to deal with human waste.

Learn more:

When Pills Fail, This, er, Option Provides a Cure (NY Times)
Faecal transplants succeed in clinical trial (Nature)
Duodenal Infusion of Donor Feces for Recurrent Clostridium difficile (NEJM Original Article)
Fecal Microbiota Transplantation — An Old Therapy Comes of Age (NEJM Editorial)
My previous posts about C. dif.:

Clostridium difficile Infections on the Increase
A New Treatment for Clostridium difficile

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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January 11, 2013 | 11:31 am

This Year’s Flu Season Isn’t Mild

Posted by Albert Fuchs, M.D.

Photo credit:
CDC

The last two years have graced us with atypically mild flu seasons. This year we’re not so lucky. The flu season seems to have started early, and at least on the East Coast is quite severe. This week Boston has declared a public health emergency as their emergency departments became swamped with flu cases. In Pennsylvania, a hospital erected a tent outside its emergency department for the increasing number of flu patients. The number of flu cases is increasing in California too, though we may be a week or two behind the wave of illness that has struck the East.

What should we all do to avoid getting sick?

• Everyone over 6 months (except for a few exceptions) should get the flu vaccine.
• If you get sick, stay home except to get medical care.
• While sick, limit your contact with others as much as possible.
• Wash your hands frequently with soap and water or with hand disinfectant, and avoid touching your eyes, nose, and mouth.

There are antiviral medicines that can decrease the duration of the flu. They are only recommended for people who are likely to have serious complications from the flu – pregnant women, older people, or people with chronic illnesses. If you are in those categories, contact your doctor at the first sign of flu symptoms. Antiviral medications are more effective the earlier they are started.

The season hasn’t peaked yet, and may turn out to be just moderate. We’ll know in a few weeks. In the meantime I recommend a little social distancing until the worst is behind us. Stay a couple of feet away from people. Say hi with a friendly wave instead of a handshake. Write an IOU to be redeemed in the spring for the hug and kiss with which you usually greet a friend. She’ll thank you if it turns out either of you is about to get sick.

And get your flu shot.

Learn more:

Flu Season Strikes Early And, In Some Places, Hard (Associated Press)
As Cases Spike, Flu Season May Be Peaking In Boston (Shots, NPR health news)
Number of NYC flu cases higher than in past years (Wall Street Journal)
Google Flu Trends for Los Angeles Seasonal Influenza: Flu Basics (Centers for Disease Control and Prevention)
Key Facts About Seasonal Flu Vaccine (Centers for Disease Control and Prevention)
Hospital Opens Emergency Tent in Midst of Increasing Flu Cases (NBC Phiiladelphia)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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January 4, 2013 | 3:37 pm

Many Women Who Don’t Need Them Are Still Getting Pap Tests

Posted by Albert Fuchs, M.D.

Cervical cells collected in
Pap tests: normal cells on
the left, precancerous cells
on the right.
Ed Uthman/Wikimedia
Commons

My regular readers know that I frequently bemoan the fact that we have no effective way to test for most cancers, and that in many cancers early diagnosis does not improve survival. Cervical cancer is one of the few exceptions. Since Georgios Papanikolau developed the test named after him, the Pap test has dramatically reduced the incidence and mortality of cervical cancer.

More recent advances have shown that cervical cancer is caused by human papilloma virus (HPV), a sexually transmitted infection. Specific testing for HPV is now frequently performed in addition to the Pap test, and a vaccine against the most dangerous strains of HPV is likely to further decrease cervical cancer incidence.

We also now understand that the changes that HPV cause are detectable years before cervical cancer occurs, so the interval between tests can be quite long. Current recommendations are for all women between the ages of 21 and 65 to have a Pap test every three years. If HPV testing is also used, women over 30 can be safely tested every 5 years.

Women over 65 who have been previously tested and have had normal test results are unlikely to benefit from further testing. Also women who have had a total hysterectomy (surgery in which both the uterus and cervix are removed) do not need further Pap tests, because they don’t have a cervix. (An important exception is women who have had a hysterectomy because of cervical cancer or pre-cancerous changes.)

This week brings us evidence of too much of a good thing. The current issue of Morbidity and Mortality Weekly Report (MMWR) published a survey of women over 65 and women who have had hysterectomies. It asked them if they had a recent Pap test. Two thirds of women over 65 answered affirmatively as did 59% of women who have had hysterectomies. I found that as surprising as if 59% of bald men were still going to their barber regularly. It’s hard to know what’s behind this behavior. These women can’t benefit from the tests they’re undergoing. Perhaps this is a manifestation of long-established habits for both the doctors and the patients. Another possible explanation is that some of the women surveyed are simply wrong. The study didn’t actually check medical records, and some of the women may have thought that they had been tested when they hadn’t. Obviously, the most pernicious possibility is that many doctors are still recommending useless testing to patients who trust them. (If Medicare paid for haircuts one wonders how many bald men would still go to their barbers, just for the attention and social interaction, and how many barbers would sent reminder postcards to their bald patients.)

So if you’re between 30 and 65 and are having both Pap tests and HPV testing and your results have been normal, give yourself 5 years between tests. And if you’re over 65 and your tests have been normal, or you no longer have a cervix, congratulate yourself for permanently escaping cervical cancer and feel free to forego further testing.

Learn more:

Pap Tests For Cervical Cancer Are Often Wasted (Shots, NPR health news)
CDC: Women with hysterectomies getting unneeded Paps (USA Today)
Cervical Cancer Screening Among Women by Hysterectomy Status and Among Women Aged ≥65 Years — United States, 2000–2010 (MMWR)
Announcement: Cervical Cancer Awareness Month — January 2013 (MMWR)
US Preventive Services Task Force recommendations for cervical cancer screening
My post in 2009 summarizing the recommendations for Pap tests: Should You Have a Pap Smear?

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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